JUL 17 1IS6 



LIBRARY OF CONGRESS. 



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Shelf QlA! 



UNITED STATES OF AMERICA. 



DISEASES 



OF THE 



NARES, LARYNX 



AND 



TRACHEA 



IN 



CHILDHOOD 



BY 



THOMAS NICHOL, M. D., LL. D., S. C. L„ 

Member of the Colleges of Physicians and Surgeons of Ontario and 

Quebec ; Member of the American Institute of Homoeopathy, 

and Corresponding Member of the Homoeopathic 

Medical Society of Pennsylvania. 




NEW YORK: 
A. L. Chatterton Publishing Company. 

1885. 




H-l 



COPYRIGHT, 1885, 
BY 

A. L. CHATTERTON PUBLISHING CO. 



MARTIN & NIPER, 

Printers, Stationers and Binders, 
218 Fulton St., Brooklyn. 



INSCRIBED TO 

ALEXANDER THOMPSON BULL, M. D., 

OF BUFFALO, 

Who77i the author is proud to claim as his preceptor in "the art 
almost Divine." 



PREFACE. 



The essays composing this volume are the fruits of thirty 
years of study and experience. Some of them appeared in 
the American Observer many years ago, and now, encouraged 
by professional friends, they appear in book form, revised 
and enlarged. The pathology of each morbid state has been 
dwelt on at great length, simply because a correct under- 
standing of the natural history of disease is indispensable 
to the scientific physician of any school. The homoeopathic 
treatment is fuller and more minute than in any similar 
work, and the author's extensive experience enables him to 
speak with some little authority on this point. Should this 
volume be favorably received, it will be followed by another 
on the Diseases of the Bronchi and Lungs. 

140 Mansfield Street, Montreal, March, 1885. 



Table of Contents. 



CHAPTER I. 

PAGE. 

Acute coyza, . . . ' . . . .25 

Definition, 25 ; etiology, 26 ; symptomatology, 27 ; prognosis, 
29 : therapeutics, 29 ; general treatment, 37 ; aphorisms, 38. 

CHAPTER II. 
Purulent coryza, ....... 39 

Definition, 39 ; etiology, 41 ; symptomatology, 42 ; progress, 44 ; 
thermometry, 44 ; pathological anatomy, 44 ; diagnosis, 45 ; 
prognosis, 46 ; therapeutics, 47 ; aphorisms, 50. 

CHAPTER III. 
Chronic coryza, . . . . . . . • 51 

Definition, 51 ; varieties, 51 ; nature, 51 ; symptomatology, 52; 
progress, 53 ; thermometry, 53 ; diagnosis, 53 ; prognosis, 54 ; 
general treatment, 54 ; therapeutics, 54 ; aphorisms, 63. 

CHAPTER IV. 
Spasm of the glottis, ...... 64 

Definition, 64 ; nature, 65 ; etiology, 67 ; symptomatology, 77 : 
pathological anatomy, 82 ; diagnosis, 84 ; prognosis, 85 ; mode 
of death, 87 ; therapeutics. 87 ; general treatment, 110: chlor- 
oform, in ; tracheotomy, Hi; aphorisms, 114. 

CHAPTER V. 

Acute catarrhal laryngitis, . . . . .116 
Definition, 116 ; varieties, 117 ; history, 117 ; etiology, 118 ; 
symptomatology, 118 ; thermometry, 121 ; pathological anat- 
omy, 122 ; diagnosis, 123 ; prognosis, 124 ; general man- 
agement, 125 ; prevention, 125 ; therapeutics, 127 ; aphor- 
isms, 131. 

CHAPTER VI. 

Acute cedematous laryngitis, ..... 132 

Definition, 132 ; etiology, 133 ; varieties, 133 ; history, 134 ; 
symptomatology. 136 ; progress, 137 ; duration, 137 ; scald 
throat, 138 ; pathological anatomy, 138 ; diagnosis, 140 ; prog- 
nosis, 142 ; therapeutics, 143 ; scarification, 149 ; tracheot- 
omy, 150 ; aphorisms, 152. 



viii CONTENTS. 

CHAPTER VII. 

Spasmodic croup, . . . . . . .154 

Definition, 155 ; frequency, 157 ; etiology, 157 ; symptomatol- 
ogy, 159 ; auscultation, 162 ; diagnosis, 163 ; prognosis, 163 ; 
therapeutics, 163 ; general management, 168 ; prevention, 
169 ; aphorisms, 170. 

CHAPTER VIII. 
Pseudo-membranous croup, ...... 171 

Definition. 173 . history, 174 ; etiology, 177 ; recurrence, 181 ; 
heredity, 182 ; contagion, 185 ; symptomatology, 190 ; mech- 
anism, 196 ; progress, 199 ; thermometry, 200 ; auscultation, 
202 ; laryngoscopy, 203 ; essential nature, 204 ; pathological 
anatomy, 205 ; diagnosis, 210 ; prognosis, 212 ; general man- 
agement, 214 ; tracheotomy, 215 ; therapeutics, 218 ; aphor- 
isms, 233. 

CHAPTER IX. 

Diphtheritic croup, . . . . . . 235 

Definition, 235 ; history, 236 ; symptomatology, 244 ; progress, 
246 ; pathological anatomy, 249 ; identity or non-identity with 
pseudo-membranous croup, 252 ; prognosis, 266 ; tracheot- 
omy, 268 ; general management, 274 ; therapeutics, 285 ; 
aphorisms, 286. 

CHAPTER X. 

Scarlatinal croup, . . . . . . 286 

Definition, 288 ; symptomatology, 289 ; pathological anatomy, 
290 ; diagnosis, 291 ; prognosis, 292 ; therapeutics, 292 ; 
prevention, 292 ; aphorisms, 293. 

CHAPTER XI. 

Tracheitis, ........ 294 

Definition, 295 ; etiology, 296 ; thermometry, 299 ; pathologi- 
cal anatomy, 299 ; diagnosis, 300 ; prognosis, 300 ; general 
management, 300 ; therapeutics, 301 ; aphorisms, 302. 



CHAPTER I. 



Acute Coryza. 



Coryza is one of the most annoying of the affections of 
infancy and childhood, and, though in general mild, it is not 
destitute of danger to very young infants. It may be defined 
to be a catarrhal inflammation of the Schneiderian membrane 
— the mucous membrane lining the nasal cavity — for " the 
nose is the classical seat of catarrh." All the ancient physi- 
cians, including the Sage of Cos himself, believed that the 
secretion of the nose flowed down from the brain, a doctrine 
that was only exploded in 1660, when Schneider, of Witten- 
berg, whose name is still given to the mucous membrane of 
the nose, showed its erroneous nature. The phenomena of 
Coryza are of great interest to the physician from the fact 
that the diseased pa^ts may be seen, and the changes which 
take place in the Schneiderian membrane are no doubt strictly 
analogous to those which take place in the mucous mem- 
brane lining the larynx and bronchial tubes. 

Generally speaking, the mucous membrane of the respira- 
tory organs is extremely sensitive in childhood, but it is a 
curious fact to which the attention of the profession was first 
called by Professor Jorg, of Leipsic, that this extreme sensi- 
bility does not exist during the first seven or eight weeks of 



26 ACUTE CORYZA. 

life. "The exposure of an infant two or three weeks old to 
a low temperature or to a vitiated air will be followed by 
disturbance of the function of the liver, and the occurrence 
of jaundice ; or, perhaps, the muscular power may be so far 
depressed as to render the child incapable of taking a full 
inspiration, so that its lungs collapse, and it dies from disor- 
der of the respiratory organs, but without the cough and 
bronchitic symptoms, which would not fail, if it were a little 
older, to announce the irritation of the mucous membrane 
of the air tube. Why this is so I do not know, but I sup- 
pose it to be the result of the generally feeble vitality which 
renders the lining of the bronchia less susceptible ; just as 
that of the intestine also seems to be at the same period, 
since, while constipation is frequent, diarrhoea is compara- 
tively rare during the first two months of life." (West.) 
But it would appear that the nasal mucous membrane does 
not possess this happy insensibility, and during the first two 
months coryza is frequently annoying and at times dan- 
gerous. 

Coryza generally results from the action of cold, from 
damp air of a low temperature, exposure to the weather, 
especially at the change of seasons, and especially is it 
caused by insufficient dress. Many people dress their little 
ones as if they possessed adamantine constitutions, and it is 
not uncommon to see a strong man warmly muffled up, walk- 
ing with a shivering urchin very insufficiently clad. In 
infants it is sometimes caused from the extremities being 
chilled by the urine if the changing of the napkin is neg- 
lected. In some instances, infants are attacked with coryza 
so soon after birth that it would almost seem that they had 
been born with it. These cases are no doubt caused by the 
sudden transition from the warm temperature of intrauterine 
life to the trying and changeable circumstances of ordinary 
existence. 

Coryza may also be produced by exposure to the heat of a 
strong fire or of the sun, and a "summer cold " is proverbi- 
ally difficult of cure. 



ACUTE CORYZA. 2*J 

Acute coryza is a prominent symptom of the first stages 
of several infectious diseases, particularly of measles. As a 
general rule, acute coryza extends downwards, though some- 
times the reverse holds good, and it may follow pharyngitis 
or laryngitis, and it is an occasional termination of bron- 
chitis. Acute coryza is sporadic and epidemic but never 
contagious, though many hold that it may be communicated 
by using the same handkerchief, thus bringing the nostrils 
into direct contact with the morbid secretion. But so far, 
no one has yet succeeded in demonstrating the contagious- 
ness of acute coryza by experiment, for Friedrich uniformly 
failed when he inoculated his own Schneiderian membrane 
with the secretion of people suffering from all stages of the 
disease. Children of all ages are liable to this affection, but 
it is most frequent in nurslings and children during the first 
years of life. As the infant grows older the liability to 
coryza increases, and the larynx and bronchial tubes are 
more likely to be involved. Female infants are more liable 
to the disease than males, from the fact that they are gener- 
ally more feeble, and the foolish pride of dress causes them 
to be less efficiently clad. 

The first symptom of acute coryza is sneezing, with dry- 
ness of the nostrils, causing a kind of snuffling respiration 
from which its common name of "snuffles" is derived, but, 
as Dr. Churchill points out, not every young infant which 
sneezes often has taken cold, for " the impression of light 
upon the branches of the fifth pair of nerves distributed to 
the eyes naturally gives rise to sneezing." Accompanying 
the sneezing is a fullness and swelling with tickling and itch- 
ing of the nostrils. In a short time there is a copious secre- 
tion of watery fluid, colorless and transparent and of a saltish 
taste, which flows in a stream from the nostrils and which 
sometimes causes excoriation of the upper lip and the sides 
of the nose. This irritating quality seems to be due to 
ammonia, and in spite of the salt taste very little sodium 
chloride is present. As the disease advances the secretion 
becomes purulent or muco-purulent. The Schneiderian 



28 ACUTE CORYZA. 

membrane is now vascular, tender and irritable, and the 
sense of smell is almost wholly suppressed. The child 
breathes by its mouth, and respiration is attended by a snuf- 
fling or rather snoring noise, which is almost pathognomonic. 
When this swelling of the mucous membrane is very consid- 
able the child is almost unable to suck, for the nostrils being 
closed, it is impossible to use the mouth for suction and 
respiration at one and the same time ; of this any one may 
convince himself by trying to suck while compressing the 
nostrils tightly. The little one attemps to nurse, but in a 
few seconds the face darkens and it desists, crying and 
lamenting. Impelled by hunger, it again attempts to nurse, 
and after repeated efforts, it finally becomes exhausted with 
hunger, fatigue and suffering. The difficulty of swallowing 
is greatly increased if the catarrhal irritation should extend 
to the fauces. 

The catarrhal irritation extends along the lachrymal pas- 
sage causing the eyes to become red and watery, and later 
the disease extends to the frontal sinuses, causing a dull 
aching pain in the forehead which the child tries to alleviate 
by rubbing the forehead with its hand or boring the head 
into the pillow. As might be expected, there is a good deal 
of fever, the pulse is quickened, the skin is hot and some 
thirst is present. The senses of taste and hearing are less 
acute than in health, though they rarely suffer to the same 
extent as the sense of smell. 

Such an attack is at its height in three or four days, after 
which it declines. The difficulty of breathing ceases, the 
discharge becomes thicker, and the danger now is that, if im- 
perfectly cured, the disease may become chronic. For some 
time after recovery the patient is liable to relapses on very 
slight exposure to exciting causes. 

The nasal mucous membrane is of a uniform red color, for 
the capillaries are surcharged with blood — at times it is red- 
dened only in .points. Soon all the subjacent tissues are 
infiltrated, and the mucous membrane becomes soft and 
swollen, and a slight swelling is sufficient to fill the nasal 
cavity, which is very small in young children. 



ACUTE CORYZA. 20, 

Coryza is a comparatively trifling disease in children of 
four or five years of age, but it is a serious disorder in nurs- 
ing infants. Dr. J. T. Meigs considers it " a serious and even 
dangerous disease," while Bouchut styles it " a very danger- 
ous disease in children at the breast.' Dr. George B. Wood 
points out that on attempting to take the breast, children 
sometimes become black in the face from suspended respira- 
tion, and that they are said occasionally to be thrown into 
convulsions by the same cause. Both Wood and West admit 
that fatal cases occur from the difficulty of breathing and 
sucking. Fraenkel remarks that a fatal termination is ex- 
tremely rare, and only takes place in nurslings owing to the 
disturbances of respiration and nutrition incident to closure 
of the nose. " While acute nasal catarrh is a complaint as 
common as it is harmless, it sometimes proves dangerous to 
infants at the breast, because the obstruction of their nasal 
passages, which are at all times narrow, makes it difficult for 
them to suck. If we do not feed with a spoon in such cases, 
life itself may be endangered in ill nourished or feeble chil- 
dren/' (Felix von Niemeyer.) 

Coryza responds readily to homecepathic treatment, es- 
pecially when it is aided by rational adjutants. 

Aconite is, according to Doctor Hayward, the best reme- 
dy for the incipient stage of coryza. As a general rule, it is 
indicated by the symptoms during the first twenty-four 
hours, and, if promptly and persistently given, it often obvi- 
ates the necessity for any other remedy. The indications 
are creeping chills, following exposure to dry, cold air or to 
a draught, and these chills are followed by burning heat, 
especially on the head and face ; spasmodic sneezing and 
discharge of a thin, watery fluid from the nostrils, with great 
thirst, especially towards evening. A short, dry cough from 
irritation of the larynx is often present and profuse lachryma- 
tion is an almost invariable accompaniment. 

The child is fearful and afraid during the day, and at 
night the sleep is restless and dream-haunted ; the patient 
feels better in a cool room. A very small powder of the 



30 ACUTE CORYZA. 

sixth or eighth decimal trituration should be given, dry on 
the tongue, every hour or every two hours. Hering does 
not recommend aconite for the primary disease, but " when 
the catarrh has been suppressed and headache is the result, 
give aconite." 

Camphor is another useful remedy in the incipient stage ; 
indeed it is of little or no use unless it is given as soon as 
the morbid state appears. Dr. Hughes considers it more 
generally useful than Aconite. " A few doses of it rapi ily 
dissipate that chilly feeling which with most persons is the 
precursor of a cold in the head." Camphor, then, is indi- 
cated by the chilly or cold stage when the malady is still in 
its incipiency ; shivering or coldness of the skin which at 
the same time is dry, and along with this there is heaviness, 
weariness and general malaise. Camphor is too much 
neglected, and this neglect probably arises from the fact 
that few practitioners carry the remedy in their pocket- 
cases. Place one drop of the Rubini tincture on a small 
piece of pure white sugar and give one-tenth of this every 
twenty or thirty minutes. I have seen decided good follow 
the repeated olfaction of the Rubini tincture. If the 
morbid state progresses, Camphor should be discontinued 
and some one of the under-mentioned remedies given. 

Nux vomica has been much recommended for coryza, 
though Dr. Hempel remarks, " we have never been so 
fortunate as to effect anything great with Nux in a catarrh 
affection of any kind." On the other hand, Dr. Hughes 
says, " for the stuffy cold I think (herein again coinciding 
with Jahr) that Nux vomica is specific ; " and Dr. Ruddock 
agrees with the recommendation. Jousset recommends this 
remedy in the incipient, dry stage of fluent coryza, and says 
that by giving a dose of the third dilution every hour he 
has often arrested the malady by the end of its first day. 
Here I must range myself on the side of my old friend, 
time-honour'd Hempel, for I have rarely seen much good 
from Nux vomica in catarrhal affections. Hering recom- 
mends Nux for the same symptoms as Arsenicum when the 



acute coryza. 31 

latter causes no improvement in twelve hours, or when the 
catarrh is fluid during the day and dry at night. Nux 
vomica is usually given during the first stage when there is 
dryness or obstruction of the nose, with heaviness in the 
forehead and impatient mood ; the mouth is dry and 
parched, without much thirst ; tightness of the chest ; 
constipation. Chills and heat alternate in the evening, and 
great heat of the face and head is present. Nux vomica has 
stoppage of the nose especially out doors but fluent indoors, 
while the Pulsatilla coryza is fluent outdoors and stoppep 
indoors. This remedy acts best in small doses of the 30th 
dilution, given in the evening. 

Mercurius is frequently given after Aconite, and is perhaps 
the most frequently indicated remedy in coryza. Hughes 
styles it '' the established remedy," though personally he 
has a preference for Euphrasia, and Bsehr says that it is " a 
distinguished remedy which will scarcely be surpassed by 
any other." The symptoms are frequent sneezing, with 
soreness and redness of the nose, and constant watery dis- 
charge which gradually becomes purulent. The smell from 
the nostrils is often offensive, and the lips are swollen and 
excoriated. The eyelids are irritated with constant shed- 
ding of tears, and this irritation may extend to the air- 
passages, causing cough with mucous rales. There is alter- 
nate heat and shivering, the heat predominating over the 
chills, with profuse perspiration which affords no relief. 
The patient feels uncomfortable in a warm room, yet cannot 
bear the cold. Hering thinks that Mercurius is especially 
serviceable for children, and Ruddock says that it is often 
useful in alternation with Nux vomica, a recommendation in 
which I cannot concur for the simple reason that we have 
no proving of the two remedies in alternation, and if we had, 
the results would be worthless. Concerning the preparation 
of Mercurius to be administered, Teste lays down " that 
corrosive sublimate is indicated in an immense majority of 
the cases which have been considered until now as belong- 
ing to the sphere of soluble mercury, provided that, with a 



32 ACUTE CORYZA. 

few exceptions, corrosive sublimate is given exclusively in 
the diseases of males, and soluble mercury in the diseases of 
females." Experience has amply confirmed this statement, 
and yet Merc. sol. acts well with children of either sex. 
Merc. corr. deserves the preference in coryza when the 
sneezing is excessive, and Mercury sol. when there is dull 
headache with great accumulation of mucus in the posterior 
nares. Mercurius acts well in all preparations, but I prefer 
small doses of the twelfth decimal trituration, dry on the 
tongue. 

Hepar is of great service when the air passages are chiefly 
affected, when the cough is loose and croupy, with rattling 
in the chest, pain in the upper part of the windpipe while 
coughing, with hoarseness. The nose is often red and 
swollen, with scabby formations in the nostrils and loss of 
smell. Hepar is especially indicated when the catarrh is 
renewed by every breath of wind, or when it affects only 
one nostril and the headache is increased by every move- 
ment. This remedy is useful in most cases of ordinary 
catarrh after partial relief from Mercurius. Hering advises 
it when the symptoms have been better and became worse 
again, and Hayward uses it " to bring up the tone of the 
parts to its natural degree." I have had the best results 
from the 12th decimal trituration. 

Arsenicum is of great service when the nostrils are stuffed 
up, with copious discharge of thin watery mucus, burning of 
the nose both externally and internally, with soreness of the 
adjacent parts. The nose is often swollen and there is 
frequent sneezing. The discharge is burning and corrosive, 
excoriating the upper lip and neighboring parts, and I have 
often verified the indication given by Jahr: " excellent if 
the nose is obstructed in spite of the copious discharge." 
There is foul smell from the nose and occasionally nosebleed 
is present. The patient is cold and chilly and the chills are 
intermixed with flushes of heat ; general debility and pros- 
tration are almost invariably present. Hering remarks that 
this remedy is indicated " when there is not much fever, 



ACUTE CORYZA. 33 

heat or thirst ; " but I think, with Baehr, that it is indicated 
" when the constitutional symptoms are very prominent and 
intense." The sufferings are relieved by warmth and exer- 
cise, and exposure does not aggravate the disease. The 
^patient is thirsty, but drinks little at a time. The remedy 
: is especially appropriate when the child has taken cold after 
a bath. As to dose, Bayes thinks that from the 3d to 30th 
will prove very serviceable, but after a long experience I 
find that I have had better results from the orthodox Hahn- 
emannian 30th than from any other. 

Chamomilla, though greatly neglected, is really one of the 
leading remedies for acute coryza in infants and young 
children, and Laurie remarks that " in the treatment of 
children this medicine is generally preferable to Nux vomica 
in arresting the attacks." Chamomilla is indicated when 
the coryza has arisen from suppressed perspiration, when a 
good deal of fever is present, one cheek being red and the 
other pale, chilliness and thirst are present, the temper is 
fretful and irritable, and the child wants to be carried all the 
time. The nostrils are often ulcerated and the lips chapped, 
and the discharge from the nose is copious and acrid. A 
hoarse cough is frequently present with rattling of mucus in 
the bronchial tubes, and this cough is worse at night, even 
during sleep. Chamomilla is doubly indicated if catarrh 
should make its appearance during dentition. Twelve years 
ago I wrote that Chamomilla should never be given lower 
than the twelfth dilution ; I am now of the opinion that I 
should have written 'thirtieth' instead of 'twelfth.' 

Belladonna is indicated by a dry, barking, spasmodic 
cough, coming on in paroxysms, apparently caused by 
titillation in the air passages, aggravated at night. Pain and 
heat in the head, eyes and nose are present, a throbbing, 
bursting headache, with flushed face and glistening eyes. 
The tonsils are swollen and red, with difficulty of swallow- 
ing and sensation of constriction in the throat. The breath- 
ing is short, anxious and hurried ; the pain in the head 
causes the child to bore its head into the pillow or to rub it 



34 ACUTE C0RY2A. 

with the hands. The fever is quite high, with alternate 
chilliness and heat. The coryza is fluent, but the remedy is 
indicated not so much by the coryza as by the other 
symptoms. Baehr recommends Belladonna if the tonsils are 
inflamed, and Jahr and Hering agree in recommending it if 
Hepar should prove insufficient. I have usually given from 
the 6th to the 12th dilutions, but have seen excellent results 
from the 30th. 

Allium Cepa is indicated when catarrh is epidemic with 
much sneezing and running of the nose, which is inflamed 
and sore down to the upper lip ; the nasal discharge is 
burning and excoriating. The eyes smart and burn, with 
profuse discharge of bland water ; tingling and itching of 
the left nostril with violent sneezing. A laryngeal cough is 
also present, which increases towards evening. The catarrh 
commences mostly on the left side and moves to the right ; 
it is worse at night and in a room, better in the open air 
and in the cold. Dr. Hering, in his lectures, was in the 
habit of insisting that Allium Cepa was the very closest 
simillimum to coryza, and he considered that it occupied a 
middle place between Aconite and Ipecacuenha. I have 
had the best results from the 12th centesimal dilution in 
repeated doses. 

Euphrasia has been too much neglected in this disease, 
though it is more used at the present time than it was twen- 
ty years ago. " It acts upon the upper portion of the res- 
piratory mucous membrane, i. e., upon the "conjunctival 
and nasal portions, only just reaching the larynx. It develops 
in this region a catarrhal inflammation, generally charac- 
terized by profuse secretion. Hence it takes a first place 
among the remedies for fluent coryza when this is a local 
affection, and not a symptom of general influenza, in which 
latter case Arsenic is preferable. The involvement of the 
conjunctiva in the catarrh is a special indication for Euphra- 
sia, and sometimes the secretion from the eyes is acrid, 
while that from the nares is bland, the opposite condition 
obtaining with Arsenic." (Hughes). The Euphrasia coryza 



acute corvza. 3$ 

is violent and profuse, excessive discharge of white mucus 
from the nostrils, and this mucus, though generally bland, is 
sometimes acrid. The eyes are red and sore and the mar- 
gins of the eyelids are occasionally ulcerated, with copious 
flow of tears. There is cough, but only during the daytime, 
and the entire disease is worse at night on lying down. 
Laurie recommends it to be given twelve hours after the 
last dose of Mercurius, if, after other symptoms having 
yielded, the flow of tears and cold in the head remain un- 
mitigated, and I have often acted on this recommendation 
with excellent results. Hughes says that " small doses of 
the mother tincture, as recommended by Hahnemann him- 
self, appears to answer all purposes excellently well." Rud- 
dock recommends from the mother-tincture to the 3d deci- 
mal dilution. Bayes says " the disease is readily cured by 
Euphrasia 6 or 12." My own experience has been made 
with the 3d decimal dilution. 

Pulsatilla is frequently suitable after Chamomilla, and, 
according to Baehr, " it may afford more relief than any other 
remedy when infants at the breast are attacked with 
catarrh, which, even if it runs its ordinary course, becomes a 
source of distress because it prevents them from nursing." 
It is indicated by a flow of thick, yellowish, fetid mucus, 
swelling of the nose with ulceration of the nostrils, frequent 
sneezing and roughness of the voice. The child is chilly in 
the evening and has whining moods, with loss of smell and 
appetite ; feels better in the fresh air, worse in the warm 
room. Jahr remarks that. " Pulsatilla is appropriate if, after 
the mucus begins to assume a thicker consistence, the nose 
is alternately stopped and running ; this remedy is scarcely 
ever indicated as long as the discharge is watery, but is very 
often better adapted to the case than any other medicine if 
the nose continues to discharge for an undue length of time 
a thick yellow or green mucus, and likewise if the nose is 
only obstructed in the evening and in the room, and runs 
again in the open air." " When nasal catarrh has passed 
into its third stage of thick and bland discharge, and is 



36 ACUTE CORYZA. 

inclined to linger, Pulsatilla is the medicine best calculated 
to hasten its departure, and may be relied on no less in 
chronic coryza of simple character and without constitution- 
al taint. It will cure even when the flux is so profuse as to 
deserve the name of rhinorrhcea," and the present writer has 
succeeded in effecting cures in a number of cases in which 
the disease had affected the frontal sinuses, with very offen- 
sive discharge. Like Chamomilla, this remedy acts best in 
the much-ridiculed thirtieth dilution. 

Sambucus is suitable for new-born infants ; the nostrils are 
obstructed by a thick, tenacious mucus ; the throat and 
mouth are dry, and the nostrils seem to be completely closed, 
yet no thirst is present. The child has sudden startings 
from sleep as if suffering. Sambucus is the only remedy 
mentioned by Hempel for this disease in children. Noack 
and Trinks recommend one drop of the mother-tincture or 
of the 1st, 2d or 3d dilution once or twice daily, and it is 
almost always given in low dilutions. 

Dulcamara is the most appropriate remedy for children 
who are subject to severe coughs, or to sore throat whenever 
they are exposed to a damp atmosphere. The patient feels 
better when in motion and worse during rest, and the slightest 
exposure renews the obstruction of the nose. In such cases 
Dulcamara is preventive as well as curative, and it acts best 
in the lower dilutions. 

Other remedies are Carbo veg. for fluent coryza with 
hoarseness and rawness of the chest ; Arum Triph. for acrid 
fluent coryza excoriating the nostrils and adjacent parts ; 
Cyclamen, the Pulsatilla of chronic diseases, according to 
Hering, for frequent sneezing with profuse discharge ; Am- 
nion, carb. for dry coryza with stoppage of the nose ; Sang. 
Canad. for fluent coryza with cough and diarrhoea ; Ipec. 
when there is difficulty in breathing, " give a couple of times " 
(Hering) ; Bryonia for hard cough with soreness of the chest, 
also for difficulty of breathing if Ipec. does not relieve 
(Hering). 



ACUTE CORYZA. 37 

Hippocrates recommended that the nose should be greased 
with the view of alleviating the difficulty of breathing, and 
this simple expedient is just as effective now as it was two 
thousand years ago. Where the nostrils are dry and ob- 
structed, injections of glycerine and tepid water afford relief. 
" During the first day or two steaming the head and face will 
afford great relief, especially if a few drops of Aconitum be 
added to the water ; and whilst giving the mercnrins inter- 
nally the same medicine may be used as spray, warm (5 grs. 
of the 1st trituration to 8 oz. of water); the patient should be 
kept to one room, and the air should be kept warm, 65 °, and 
moist by having steam continually escaping into it." (Hay- 
ward.) " If the nasal obstruction is such that it entirely 
prevents respiration and suction, the physician should at- 
tempt the introduction of a small silver tube into each nos- 
tril ; it should be flattened, and curved from before back- 
wards following the course of the floor of the fossae, and 
afterwards fixed under the nose with the neighboring tube. 
These two provisionary canulae allow the passage of air, and 
prevent the child from dying at once, by giving the disease 
time to cure itself." (Bouchut.) 

Dr. Charles D. Meigs directs a flannel cap to be put upon 
the child and worn for two or three days. The cap should 
be removed as soon as the coryza is relieved, as otherwise 
the child is apt to become so accustomed to it as to take 
fresh cold when it is removed. Dr. Ruddock thinks that 
infants should be taught to breathe through the nostrils, 
especially during sleep, but I fear that is " easier said than 
done." 

Of all the auxiliary measures that have been recommended, 
I have found the " thirst cure" the most efficient. It was 
first suggested by Dr. C. J. B. Williams in the Cyclopaedia of 
Practical Medicine, and is a most powerful means of cure. 
" It is the acrimony of this discharge (from the pituitary 
membrane) which reacts on the membrane and keeps up the 
inflammation and its accompanying disagreeable circum- 
stances. On this circumstance depends the efficacy of a 



38 ACUTE CORYZA. 

measure directly opposed to that just noticed, but to the 
success of which we can bear decided testimony — we mean 
a total abstinence from liquids. This method of cure oper- 
ates by diminishing the mass of fluid in the body to such a 
degree that it will no longer supply the diseased secretion. 
The coryza begins to be dried up about twelve hours after 
leaving off liquids; from which time the flowing to the eyes 
becomes gelatinous, and between the thirtieth and thirty- 
sixth hour ceases altogether. The whole period of absti- 
nence needs scarcely ever to exceed forty-eight hours." The 
thirst cure is, of course, not suitable for nursing children, but 
for those who are past that stage I know no better aid to 
the homoeopathic remedies. 

Dr. Constantine Hering in his lectures was much in the 
habit of dwelling upon the connection between the use of 
salt and sugar on the one hand and coryza and catarrhal 
affections on the other. "If a patient is subject to very 
frequent recurrence of catarrhs which are very difficult of 
cure, it will often be found that he eats too much salt. In 
this case he should be as moderate in the use of salt as pos- 
sible, and smell now and then sweet spirits of nitre." And 
again, " Never suppress a cold either by cold or drugs, it is 
always a purifying process. Nobody takes cold who has not 
other impurities in his system. One is much more liable to 
catch cold after eating or drinking sharp, superfluous or indi- 
gestible things. Many children will not get rid of a cold as 
long as they indulge in too much sugar, syrup and other 
sweets." 

Aphorisms. 

i. Snuffling of the nose, with its attendant difficulty in 
breathing, at once calls our attention to coryza. 

2. Coryza is not a dangerous disease, save in the case of 
feeble infants, for fatal cases undonbtedly occur from the dif- 
ficulty of breathing and sucking. 

3. Aconite and Camphor are the leading remedies for the 
early stages, and Mercurius and Arsenicum for the more 



PURULENT CORYZA. 39 

advanced, but Euphrasia, Chamomilla and Allium Cepa have 
hitherto been too much neglected. 

4. The thirst cure is the most effective,, of the accessary 
means of cure, and, according to Constantine Hering, the 
immediate use of salt is one of the chief predisposing causes, 
while the immediate use of sugar hinders the cure. 



CHAPTER II. 



Purulent Coryza. 



Purulent coryza, called by Underwood coryza maligna or 
morbid snuffles, is an inflammation of the mucous membrane 
of the nose in infants which, still being acute, differs from 
simple coryza in the much graver character of its symptoms. 
Its distinguishing feature is the presence of a purulent secre- 
tion accompanying an inflammation of a more or less malig- 
nant nature ; Dr. Fraenkel, who has given us an excellent 
essay on this disease, thinks that it would be etymologically 
more correct to call it a pyorrhoea than a blennorrhcea. This 
morbid state rarely occurs alone, being often associated with 
angina, conjunctivitis or otitis, and in my own practice I 
have seen purulent coryza as a sequel of scarlet fever, diph- 
theria and measles. In these cases a pseudo-membranous 
exudation is present which is frequently not to be distin- 
guished from a diphtheritic membrane. In illustration of 
this variety of coryza I quote the following instructive case, 
occurring as a complication of scarlatina, from Dr. Charles 
West: " In this instance, a little boy, six months old, was 
brought to me on the 25th of October, 1842. His health 
had been good until the 20th, when he became hoarse ; on 



40 PURULENT CORYZA. 

the 22d this hoarseness had much increased, and he became 
unable to suck, since which time he had continued to grow 
worse. When I saw him his skin was warm, face rather 
flushed, eyes watering, and a thick, ropy musus obstructed 
his nostrils. He cried with a suppressed but squeaking voice, 
and breathed with a peculiar wheezy noise, though air enter- 
ed the chest unattended with any rale. The child was una- 
ble to suck, and even when he drank from a cup the fluid 
often returned through his nose. The inside of the mouth 
was very red, and the tonsils and soft palate were especially 
so. The mouth was full of an extremely tenacious mucus, 
which it was necessary from time to time to take out with 
the hand. A lotion was injected up the nostrils, composed 
of 3 j of alum to § ij of water, with great relief to the child* 
the secretion from the nares becoming more decidedly puri- 
form, but less adhesive ; and the child became able to suck 
a little. On the 28th, however, the child's powers seemed 
much depressed ; it sucked eagerly, for the secretion from 
the nose had become almost watery, but it swallowed with 
much difficulty. A layer of false membrane of a yellowish- 
white color had now appeared on the soft palate and back of 
the hard palate, and on the tonsils. A lotion of three grains 
of nitrate of silver to an ounce of water was applied to the 
back of the throat, and a mixture of the extract of bark with 
ammonia was given every six hours. On the first of Novem- 
ber the ehild was better, could both swallow and suck well, 
and the false membrane had entirely disappeared from the 
mouth ; but the palate was still red, and presented some 
broad superficial patches of ulceration. The subsequent 
recovery was tardy, but the immediate danger was over, and 
no relapse occurred." No one can doubt but that at the 
present day this case would be pronounced diphtheritic by 
well-read and experienced practitioners of all schools, and 
probably Dr. West himself would now be of that opinion. 
Denman describes an epidemic of this disease under the 
name of coryza maligna, and he states that in connection 
with the coryza there was a general fulness of the throat 



PURULENT CORYZA. 41 

and neck externally ; that the tonsils were tumefied, and of 
a dark-red color, with ash-colored specks, and in some cases, 
with extensive ulcerations ; and that some of the children 
swallowed with difficulty. Meigs and Pepper, in comment- 
ing on Denman's remarks, say, "there can therefore be little 
doubt but that in reality these were cases of nasal diphthe- 
ria," but most observers would omit the adjective nasal and 
simply call them diphtheritic. 

Purulent coryza chiefly occurs on the Continent of Europe, 
especially in the Foundling Hospitals ; less frequently is it 
found in Great Britain, while on this continent the disease is 
so seldom seen that many practitioners have never seen a 
case. On the whole, then, purulent coryza is a somewhat 
rare disease, so much so that Rilliet and Barthez, the leading 
French writers on the diseases of children, do not even men- 
tion it. It affects both sexes with like frequency, and is 
usually seen in the newly-born, and hardly ever in children 
over twelve months. 

The causes of simple acute coryza, exposure to a damp or 
cold atmosphere or neglect in changing the infant's clothing, 
have but little influence in causing the much more serious 
purulent coryza, though unquestionably a certain proportion 
of cases arise from accidental aggravations of the milder dis- 
ease, and I attended a case in which this result was produced 
by exposure of a child suffering from the simple form of 
coryza to the heat of a strong fire. But the most influential 
factor in the etiology of this disease is undoubtedly the infec- 
tion of the mucous membrane of the child's nose with the 
secretions of the maternal vagina during birth, so that the 
disease is strictly analogous to ophthalmia neonatorum. This 
view of the chief cause of the disease is confirmed by the 
facts that it almost invariably appears during the first days 
of life ; that it rarely attacks children whose mothers are not 
suffering from leucorrhcea or some similar malady: and, last- 
ly, that it is most frequent in little ones who, from various 
causes, have been long detained in the maternal passages 
during birth. Then again, in the great majority of cases, all 



42 PURULENT CORYZA. 

other causes of the disease, save infection by maternal secre- 
tions, can be excluded with almost absolute certainty. It is 
worthy of remark that ophthalmia neonatorum is much more 
frequent than purulent coryza caused by the maternal secre- 
tions, and this comparative immunity of the nasal passages 
probably arises from the movements of the eyelids favoring 
the entrance of the infecting matter in the one case, while in 
the other the ciliated epithelium of the nasal mucous mem- 
brane probably acts as a protector against the materies 
morbi. 

As soon, then, as the child is born, or at least a very brief 
period after birth, a watery, bloody discharge from the nose, 
accompanied by sneezing, announces the onset of the disease. 
Sometimes stoppage of the nose precedes the discharge, but 
as a general rule the latter, which is the pathognomonic 
symptom of the disease, makes its appearance first. This 
discharge is usually yellow in color, odorless, at first glutin- 
ous, but soon it becomes thicker and purulent with a peculiar 
smell, which, however, differs from the fetid odor of chronic 
coryza. At times it resembles the " laudable pus" of the 
older surgeons, at times it has the color of prune juice from 
an admixture with blood, but, as a general rule, it is puru- 
lent, rarely mucous. Later it is thickish, rather solid in con- 
sistence, especially when the cause of the disease is infection 
from the maternal secretions. A thin, ichorous discharge, 
containing at a later date small granular particles — really the 
detritus of the pseudo-membrane — indicates the presence of 
false membrane, which, on examination by a' strong light, is 
seen covering the nasal mucous membrane with a uniform 
yellowish-white coating. Soon the alae nasi and adjoining 
parts are inflamed and swollen, and the red and shining skin 
is really the seat of an erysipelatous inflammation. The 
upper lip is red and swollen, and, at a later stage, it is exco- 
riated by the secretions. I have never noticed "the curious 
purple streak on the margin of the eyelids " which Denman 
considered to be pathognomic ; and in many cases there is a 
fulness and swelling about the throat and neck externally, 



PURULENT CORYZA. 43 

resembling the well-known enlargement of diphtheria. 

The swelling of the nasal mucous membrane is much 
greater than in the simple coryza, and, as a result, the breath- 
ing is difficult, nasal and snoring. Young infants breathe 
almost exclusively by the nostrils, and when these are plugged 
by the inspissated secretion of this disease, they seem to 
be quite unable to keep the mouth open in order to compen- 
sate for the closure. When the mouth is kept open it, 
together with the tongue and throat, becomes dry and stiff, 
and the infant makes such violent efforts to breathe as to 
conduce greatly to a fatal termination to the disease. When 
the nostrils are closed the child, unable to breathe and suck 
at the same time, refuses the breast, or only nurses at con- 
siderable intervals and with great difficulty. Cough is rarely 
present, except in those cases in which the disease has 
extended to the fauces ; bleeding from the nose sometimes 
occurs in the pseudo-membranous form of the disease. 

The general appearance of the child, from the very begin- 
ning, indicates a serious malady, quite different from even 
severe cases of simple acute coryza, for in addition to the 
intense inflammation of the entire nasal mucous membrane, 
there is great constitutional debility present in almost all 
cases. The violent attacks of dyspnoea are, of course, the 
result of the closure of the nostrils, and the restlessness, de- 
pression and emaciation are the expression of the constitu- 
tional disease. The skin becomes dry and harsh, and as the 
emaciation progresses it becomes wrinkled, and low fever and 
somnolence are frequently seen in advanced stages. I have 
never met with the disorder of the bowels, with thick, pasty 
stools of a green or blue color, of which Fleetwood Churchill 
speaks. 

In favorable cases the inflammation with its accompanying 
discharge diminishes, the swelling of the nasal mucous mem- 
brane — which carries with it so much of danger — subsides, 
breathing becomes quite easy, and the child soon enters upon 
convalescence. Of course, as soon as the nasal passages per- 
mit free respiration the act of sucking becomes easy, and 



44 PURULENT CORYZA. 

with this the debility and emaciation soon pass away. But 
all cases have not this favorable termination, for the little 
one may perish from inanition caused by pain, fatigue and 
insufficient nourishment, and the fatal result is ushered in by 
drowsiness which soon deepens into coma. Death, in these 
cases, is often caused by effusion on the brain, and, indeed, 
severe brain symptoms are frequently associated with puru- 
lent coryza. 

Violent cases of this disease may prove fatal in three or 
four days, and milder cases may run on for a week or ten 
days before amendment takes place, but even then final re- 
covery only comes after careful treatment of the destructive 
processes in cartilage and bone so apt to follow severe ulcer- 
ative inflammation. The duration of the disease depends 
greatly upon the age of the patient, for in very young infants 
the fatal termination is always nearer at hand and always 
more threatening than when the patient is at least a year old. 

In severe cases of purulent coryza, the thermometer shows 
a temperature of ioi° to 104 , and such high temperatures 
add very greatly to the danger. Still, in one malignant case 
which I attended^in the year i860, the temperature was quite 
low throughout, and a moderate temperature is no guarantee 
for a favorable termination, especially if the disease tends to 
assume the malignant form. 

Dr. Denman, the celebrated accoucheur, met with an un- 
usual number of cases of purulent coryza, encountering eight 
cases in eight months, of which six died. One of the bodies 
was opened by John Hunter and Sir Everard Home, who 
detected nothing save that the nasal mucous membrane was 
of a dark-red color, and its blood-vessels more turgid than 
usual. Later observers note that the mucous membrane is 
softened as well as thickened throughout the entire extent 
of the nasal fossae, and that the membrane is thickly coated 
with pus or a thick, tenacious mucus. On removing this 
mucus exuded blood is seen, mostly in minute points, which 
were thrown out in the course of the disease. In other cases 
patches of the pseudo-membranous exudation are found 



PURULENT CORZA. 45 

scattered over the surface of the nasal mucous membrane, 
and this exudation is not necessarily diphtheritic. In other 
cases again the swollen mucous membrane; of a vivid red 
hue, is covered throughout its entire extent with a closely- 
adherent pseudo-membrane which extends over the entire 
interior of the nares, and these are the cases which it is 
almost impossible to distinguish from diphtheria. On re- 
moving the pseudo-membrane the subjacent mucous mem- 
brane is found to be softened and extremely ulcerated. 
Bouchut remarks that very commonly the false membranes 
are not situated in the interior of the nasal fossse, but only 
at the orifice of the nostrils. Purulent coryza can hardly be 
confounded with simple acute coryza, for the violent inflam- 
mation with purulent discharge of the first-named is entirely 
different from the catarrhal inflammation with mucous dis- 
charge of the other. The differential diagnosis between 
purulent coryza and diphtheria is much more difficult, and 
in the advanced stages of the disease it mainly rests on the 
presence or absence of the characteristic diphtheritic blood- 
poisoning. If a false membrane is distinctly visible in the 
nasal passages, or if the nasal discharge is loaded with minute 
fragments of false membrane, and if this is followed by the 
well-known symptoms which mark the constitutional infec- 
tion of diphtheria, there can be no room for doubt, and the 
disease is diphtheria beyond a doubt. But when a pseudo- 
membrane lines the nasal passages without constitutional 
symptoms following, it is likely that the disease is not diph- 
theria, for not all false membranes are diphtheritic, and most 
experienced practitioners have met with cases of pseudo- 
diphtheria which present a most wonderful resemblance to 
the genuine disease. Again, isolated patches are likely to 
be non-diphtheritic, while a continuous coating of false mem- 
brane is almost certainly diphtheritic. Abscess of the nose 
has some resemblance to purulent coryza, but abscess rarely 
appears on both sides of the nose, while purulent coryza, as 
a very general thing, affects both sides with like virulence. 
Then the course of the diseases differs much, for in nasal 



Ajo purulent coryza, 

abscess the one-sided inflammation is, after a few days, re- 
lieved by a discharge of pus which brings welcome repose to 
the patient, while in purulent coryza the virulent inflamma- 
tion is accompanied by purulent discharge almost from the 
beginning. Purulent coryza has been confounded with croup, 
though it is difficult to understand how any one could make 
the mistake, for the whistling inspiration and sudden dysp- 
noea which follow the closure of the nasal passages are wholly 
unlike croup, and the application of the stethoscope to the 
larynx, which should never be omitted in croup and, indeed, 
all laryngeal diseases, soon makes the case clear. Purulent 
coryza may possibly be confused with syphilitic coryza, but 
the history of each case must be carefully investigated, the 
entire course of the disease is different and the characteristic 
eruptions soon clear up the diagnosis. Later it will be con- 
firmed by the changes in the shape of the central incisors of 
the upper jaw, first clearly pointed out by Jonathan Hutch- 
inson. 

Purulent coryza is always a serious disease, and the danger 
in each particular case depends much upon the degree of 
tumefaction of the nasal mucous membrane and upon the 
consistence of the secreted fluids, for upon these two factors 
of the disease depend the ability to breathe and to suck. 
Denman lost three-fourths of his cases, and Meigs and Pep- 
per say that " the two cases of idiopathic membranous coryza 
in infants that came under our observation both proved 
fatal," while "the four cases in older children recovered with- 
out any difficulty." A good deal depends on the age of the 
patient. A feeble, newly-born babe offers little or no resist- 
ance to a severe attack of purulent coryza, but a stout little 
one, of say nine months, may get through even a severe 
attack. The pseudo-membranous form is more dangerous 
than the purulent, for, as has been already remarked, many 
cases of the pseudo-membranous variety are really diphthe- 
ritic, though perhaps an equal number are strictly analogous 
to the well-known pseudo-diphtheria. 

The nasal secretions should be removed as they collect, 



PURULENT CORYZA. 4 1 / 

though this would be bad practice if a tightly-adherent 
pseudo-membrane is present. To soften the secretions a 
very small quantity of tepid water may be thrown into the 
nares by means of a small syringe, and the passages may 
then be cleansed with a camel's hair pencil. Fraenkel re- 
marks that infants must not receive injections into the nose 
while lying down, as in this position the medicated fluids are 
very apt to pass through the pharynx into the opening of 
the larynx, producing severe spasm of the glottis. Indeed, 
the child should be kept as much as possible in an upright 
posture, and the little one's mouth should be kept open in 
severe cases. When the nostrils are completely blocked the 
child should not be put to the breast, but the maternal milk 
should be given from a spoon. It is in this disease rather 
than in simple acute coryza that the nasal tubes of Bouchut, 
mentioned in the preceding chapter, are useful. Tubes of 
soft rubber would be preferable to silver ones, though the 
latter would suit best if the nasal secretions are both thick 
and firm. 

I am not aware of the existence of any essay on the 
homoeopathic therapeutics of purulent coryza, so I will first 
state my own experience in the disease, and then briefly 
indicate the remedies which will cure every curable case, for 
some cases of this disease are incurable in that very nature. 
My experience includes three well-marked cases, and these 
were cured with Argentum nitricum, Nitric acid and Apis 
mellifica, each with a single remedy, unaided by any adju- 
rant save attention to cleanliness. 

The disease has, save in the well-marked pseudo-membran- 
ous form, an etiology which is identical with that of ophthal- 
mia neonatorum. Now Argentum nitricum is the leading 
remedy for ophthalmia neonatorum, and Dr. Hughes writes 
as follows: "I myself have been so satisfied with even its 
internal effects in ophthalmia neonatorum that I have never 
had to resort to any external measures beyond those needed 
for cleanliness." The experience of our American oculists is 
quite confirmatory of its power over such purulent inflamma- 



48 PURULENT CORYZA. 

tions of the conjunctiva. Dr. Angell commends the remedy 
" in affections of the lining membrane of the lids, and of the 
lachrymal duct and sac, when there is an abundant discharge 
of pus;" and Drs. Allen and Norton write: "The greatest 
service that Argentum nitricum performs is in purulent 
ophthalmia. With large experience in both hospital and 
private practice, we have not lost a single eye from this dis- 
ease, and every one has been treated with internal remedies, 
most of them with Argentum nitricum of a high potency, 
30th or 200th. We have witnessed the most intense chemo- 
sis with strangulated vessels, most profuse purulent discharge, 
even the cornea beginning to get hazy and looking as though 
it would slough, subside rapidly under Argentum nitricum 
internally." 

In my first case the child was two months old, weak and 
scrofulous ; the mother had suffered for years from a very 
profuse leucorrhcea. Ophthalmia neonatorum was present 
as well as purulent coryza, so that there could be no doubt 
as to the etiology of the disease. The nose was red, swollen 
and painful, especially over the nasal bones. Several pimples 
studded the tip and neighboring parts, and these red and 
angry pimples speedily opened and became small ulcers. 
The discharge was thick, yellow and blood-streaked, and 
twice a small hemorrhage made its appearance. The child 
was gloomy and sad, and the entire state was worse after 
midnight and also in the morning. I gave Argentum nitri- 
cum, 1 2th centesimal dilution, and both ophthalmia and 
coryza were cured in a fortnight. No external applications 
were used, save abundance of tepid water. 

In my second case there was a very strong suspicion, 
almost amounting to certainty, of a syphilitic taint. The 
child was four and a half months old, wan and withered, with 
pinched features and skin drawn tightly over forehead and 
cheek-bones. The mucous membrane of the nose was ulcer- 
ated, with a constant discharge of thin, bloody, fetid sanies, 
which corroded the upper lip. The nose was of a vivid red, 
and studded with small yellowish vesicles which broke and 



PURULENT CORYZA. 4§ 

formed scabs. As the disease advanced the nasal discharges 
became thick and yellowish, but the streaks of blood disap- 
peared. The fetid smell lingered to the last, and we had 
three somewhat profuse hemorrhages of dark blood, all in 
the night-time, without any special cause. The aversion to 
the open air was very marked, but cold weather agreed best 
with the child. I gave Nitric acid, 1 2th centesimal dilution, 
and the child improved at once, though it took three months 
to complete the cure. No other remedy was used. 

My third case was cured with Apis mellifica, 6th decimal 
trituration. It was a well-marked specimen of the pseudo- 
membranous variety of the disease, the nares being coated 
with a false membrane which yet was not diphtheritic, 
for it lacked the fetor which is almost part and parcel of 
diphtheria, and no constitutional symptoms accompanied or 
followed the local disease. The nose was greatly swollen, 
red and cedematous, and so marked were these external 
symptoms that the relatives of the child at first thought that 
the disease was erysipelas. The mucous membrane swelled 
to such an extent that the nose was completely stopped up 
— even before the appearance of the false membrane. The 
inflammatory action was followed by the exudation of a ten- 
acious, gluey mucus, which speedily became organized into 
a well-marked false membrane, on removing which the sub- 
jacent mucous membrane was seen to be still swollen and 
studded with minute bleeding points. The morbid action 
extended to the fauces and even threatened the larynx, but 
finally made a good recovery in twelve days. 

Aconite would only be of value in purulent coryza if ad- 
ministered very promptly, almost before the morbid state 
had time to develop itself, as it were ; if given afterwards 
it would cause the loss of valuable time. Belladonna is more 
frequently indicated than Aconite, corresponding as it does 
not merely to the symptoms of the malady, but to the path- 
ological state of which the symptoms are the expression. 
Leading remedies are Mercurius solubilis, Hepar sulphuris, 
Arsenicum album, Calcarea carbonica, Pulsatilla, Sulphur, 



50 PURULENT CORYZA. 

Silicea, Aurum muriaticum, Lachesis and Kali bichromicum, 
the two last mentioned being especially effective in the 
pseudo-membranous form of the disease. For the special 
indications I must refer the reader to Chapters I and III of 
this volume. 

Aphorisms. 

1. Purulent coryza is a malignant inflammation of the 
nasal mucous membrane of infants characterized by a pro- 
fuse purulent discharge and, at times, the formation of false 
membranes which yet are not diphtheritic. 

2. Purulent coryza is chiefly caused by actual contact of 
the infant's nose with morbid secretions of the maternal pas- 
sages during birth, and hence the disease is closely analogous 
to ophthalmia neonatorum. 

3. Purulent coryza is comparatively a rare disease, and the 
mortality, even under the most enlightened treatment, is 
probably at least one-half of the whole number attacked. 

4. The pseudo-membranous form of purulent coryza is 
distinguished from true diphtheria of the nasal passages by 
the presence of constitutional infection when the disease is 
diphtheria, and also by the fact that true diphtheria rarely 
attacks the nose alone. 

5. The remedies which have proved successful in the 
writer's hands are Argentum nitricum, Nitric acid and Apis 
mellifica ; other remedies are Sulphur, Mercurius solubilis, 
Arsenicum album, Aurum muriaticum, Lachesis and Kali 
bichromicum, the two last named especially in pseudo-mem- 
branous cases. 



CHAPTER III. 



Chronic Coryza. 



Chronic coryza of infants is comparatively rare, but as it 
is exceedingly difficult of cure, it is advisable to describe the 
disease and its treatment as fully as possible. This intract- 
ability arises from the constitutional taints which so often 
lie at the root of the local affection, which, in these cases, 
is merely a manifestation of a constitutional disease. 

Chronic coryza may be defined to be the morbid state 
which follows a neglected or partially cured acute coryza. 
Ulceration may be present, but simple, chronic inflamma- 
tion of the Schneiderian membrane is the most common 
pathological state. There are then several varieties of chronic 
coryza. The most common of these is the simple form de- 
pendent on chronic inflammation, and the constitutional 
state here is a low condition of health, with mal-nutrition 
and anaemia. Next in frequency we have the scrofulous 
variety, exceedingly intractable in its nature, but still quite 
amenable to homoeopathic treatment ; and the syphilitic 
variety, the most formidable of them all, but which, as 
Bouchut, long ago pointed out, is cured more easily than 
the others. 

Chronic coryza is not nearly so common as acute coryza, 
and, if all cases of the last mentioned were carefully attend- 
ed to, the chronic variety would become still more rare. So 
far as I have observed, it is not more frequent in children 
of one sex than of the other. Some fault of the general 
health, some obscure constitutional dyscrasia is almost inva- 
riably the predisposing cause of chronic coryza, and Fraenkel 
remarks " that acute rhinitis may pass into the subacute and 



§2 CHRONIC CORY2A. 

chronic forms, and yet in the vast majority of cases this only 
takes place \w persons suffering under a dyscrasia!' In not a 
few cases, however, children not suffering from any dyscrasia 
may have repeated attacks of acute coryza which finally ter- 
minates in the chronic form. 

The principal symptoms of chronic coryza, as might be 
expected, are of a strictly local character. The respiration 
is nasal, and embarrassed even during the day, and at night 
the obstruction of the nostrils gives rise to snoring, or rather 
hissing sounds. The child's rest is disturbed by the necessity 
of making increased muscular effort to fill the chest with air, 
and as a result, the sleep is broken and restless. In aggra- 
vated cases the difficulty of breathing is so great that the 
blood becomes so thoroughly carbonized, that the sleep is 
heavy and restless. On examining the nasal passages the 
mucous membrane will be found to be thickened and inject- 
ed. In the earlier stages it is more highly vascular than 
natural, and here and there slight excoriations are visible. 
As the malady advances the mucous membrane becomes 
pale, bloodless, and devoid of its natural velvet-like lustre. 
In many cases the amount of secretion is so much smaller 
than in acute coryza that they are spoken of as " dry ca- 
tarrhs," while in others the secretion is purulent and very 
abundant. Whether scanty or copious, the secretion is so 
viscid as to form scabs and crusts, or even small lumps of 
inspissated mucus, and this combined with the thickened 
state of the mucous membrane causes a true stenosis of the 
nostrils. These crusts are moist and greenish in the earlier 
stages, and dry and blackish in the more advanced phases 
of the disease, and if they contain blood they are dark red- 
dish in color and friable in texture. Very little causes the 
child's nose to bleed, and these frequent hemorrhages often 
cause the physician to be consulted. As the disease ad- 
vances the voice changes and becomes markedly nasal. In 
chronic coryza we do not find the prickly itching in the 
nostrils, the sneezing or the frontal headache that are so 
prominent in acute coryza, though in some instances the 



CHRONIC CORYZA. 53 

child would seem to suffer from frorital headache, judging 
from the manner it rubs its forehead against the nurse's 
shoulder. The decomposition of the secretion gives rise to 
a more or less intense smell from the nostrils and even from 
the mouth, a peculiar odor given off with the expired air, and 
when this symptom is present, the disease is called ozcena. 

As the disease advances, the general appearance of the 
patient gives evidence of greatly impaired health. The 
face is pale, the complexion is dusky, the features lose their 
lively expression, and all the movements of the child show 
languor and listlessness. The sleep is unrefreshing, the 
appetite is capricious and finally fails altogether, and nutri- 
tion becomes seriously impaired. The tongue is pale and 
flabby and more or less coated, and either constipation is 
present, or constipation alternates with diarrhoea. 

Chronic coryza is one of the least self-limited of all 
diseases, running on indefinitely till cured. It is useless to 
look for a cure short of several months, for there is a strong 
predisposition to acute exacerbations of the original disease. 

In the earlier stages of chronic coryza the thermometer 
shows little alteration of temperature, but as the disease 
advances a kind of mild, hectic fever is developed and the 
evening temperature rises one or two degrees. This mostly 
occurs with delicate children in whom there is possibly a 
suspicion of scrofula. During the acute exacerbations the 
temperature rises, as a matter of course. 

The nostrils should be carefully examined by a full light, 
and, at the same time, the fauces should be examined with 
equal care. In infants, rhinoscopic examinations are almost 
impossible, and it is not always easy to get older children to 
submit to them, but they should be instituted whenever 
practicable. 

The diagnosis is easy if proper care is used in the exami- 
nation. The teeth should always be examined, as the foul 
odor may arise from dental caves, and collections of matter in 
the follicles of the tonsils may give rise to similar symptoms. 
The differential diagnosis between the several varieties of 



54 CHRONIC CORYZA. 

chronic coryza — ulcerative, syphilitic, and scrofulous — must 
be based upon the most careful and thorough investigation of 
the history of each case ; for the syphilitic and scrofulous 
varieties are only to be distinguished from the form dependent 
on simple chronic inflammation by their histories. A seated 
pain in the cheek or forehead would indicate extension of the 
disease to the antrum of Highmore or to the frontal sinuses. 
Young children would make this known by rubbing the 
affected parts against the pillow or against the nurse's 
shoulder. 

Very few children die from chronic coryza, so that a favor- 
able prognosis must be given as far as life is concerned, but 
it is a most obstinate disease, and, even under the most 
enlightened homoeopathic treatment, it requires a number of 
months to effect a cure. A good deal depends upon the 
stage of the disease at which the patient comes under treat- 
ment ; for if the case is seen early the prognosis is more 
favorable than if the case has progressed to atrophy of the 
nasal mucous membrane. 

In the management of the chronic coryza of infant's, cloth- 
ing is even more important than diet. Flannel undercloth- 
ing must be insisted on during the cold months of the year, 
and merino underclothing should be worn in summer. The 
underclothing, even in summer, should come high up on the 
neck, and both upper and lower limbs should be protected, 
for countless cases are caused and finally goaded into in- 
curability by the foolish custom of leaving the legs of tender 
infants almost naked. The diet should be plain, but nutri- 
tious, and all rich foods should be carefully avoided. 

Sulphur is a leading, in fact an almost indispensible reme- 
dy in chronic coryza of children. It is indicated in weakly 
children of psoric constitution, for almost all the little ones 
helped by this great polychrest have suffered from eruptions 
on the skin, or from diarrhoea. In such patients the skin is 
unhealthy, and every little injury inclines to suppurate and 
to heal slowly. The nostrils are excoriated and ulcerated, 
with profuse discharge of thick, yellowish or greenish puri- 



CHRONIC CORVZA. 55 

form mucus, and frequently the nose is obstructed by hard, 
dry scabs, with frequent bleeding from the nose. In almost 
every case the nasal discharges have an, offensive smell. 
Sulphur is well indicated if, in the progress of the disease, 
the cartilages become inflamed and swollen. The patient 
has frequent weak, faint spells, with coldness of the extremi- 
ties and even general chilliness of the body, and it has long 
been noticed that such patients are very liable to take cold. 
The 30th is here the most effective preparation, but I have 
used Boericke and Tafel's 200th with fine results. 

Calcarea carbonica is classed by Jahr — in company with 
Sulphur and Silicia — as being one of the most reliable reme- 
dies for chronic coryza. The fore part of the nose is red, 
inflamed and swollen ; The nose is dry and of very offensive 
smell ; the nostrils are sore and ulcerated ; the discharge 
may be thick and pus like, or thin and watery. The mucous 
membrane is frequently moist during the day and dry at 
night. The little patient has a tendency to enlargement of 
the glands, and profuse sweat is often present, especially 
about the head and feet. Patients for whom Calcarea car- 
bonica is suitable are very susceptible to external influences, 
as currents of air, cold, heat, noise and excitement. It 
is an additional indication when the catarrhal irritation ex- 
tends from the nostrils to the air passages ; hoarseness is 
a leading indication. " No remedy will be more frequently 
needed in irritations and sub-acute inflammations of the 
mucous membranes. Even in catarrhs which run on into 
structural degradation, simulating phthisis, it has proved to 
be the curative remedy, and the question may be raised if 
it will not arrest phthisis. A good remedy in scrofulous 
ozaena." (Brigham.) I have almost invariably used the 
orthodox 30th dilution, but, as Hughes well remarks, " the 
3d is undoubtedly efficacious." 

Silicia is one of the invaluable remedies with which we 
combat the deep-seated, morbid processes which occasionally 
attack the bones of the nose, even extending to the cribri- 
fornTplate of the ethmoid bone. The tip of the nose is 



$6 CHRONIC CORYZA. 

sensitive to contact ; the mucous membrane is excoriated 
and covered with crusts ; ulcers are found high up in the 
nostrils. It has been found useful in inveterate, dry coryzas, 
also in chronic ulceration of the Schneiderian membrane,with 
discharge of acrid water which makes the inner nose sore and 
bleeding. In Silicia the coryza is dry oftener than fluent ; 
the contrary is the case with the coryzas of Aurum, Alumi- 
na, Arsenicum, Asafcetida, and Baryta carbonica. " The 
perspiration on the head is more in Silicia than Calcarea, 
and if covered lightly soon becomes warm ; sweats more 
often towards morning." (Brigham.) I have never used 
Silicia lower than the 12th and have had excellent results 
from the 20th and from Boericke and Tafel's 200th dilution. 
Kali bichromicum is a principal remedy for catarrhal in- 
flammations involving nearly the entire respiratory tract, as 
well as the nasal passages. It has a very wide range of 
action, and has probably been less administered, at least on 
this side of the Atlantic, than it deserves. " It is one of the 
few drugs beneficial in caries of the bones of the nose, and 
useful in combating the constitutional effects of syphilis, 
when complicated with catarrhal affections of the nose and 
throat." (Morse.) The Kali bichromicum catarrh usually 
begins with a profuse mucous discharge, which at first is 
clear as water, but as the disease progresses the discharge is 
thick, tough mucus, which finally, on drying, fills the nose 
with hard, elastic plugs. Great pain is caused by the re- 
moval of these hardened masses, and they leave the nose 
very sore. There is a great accumulation of tenacious, 
ropy mucus, which is so viscid that it may be drawn out 
like a long thread, and the pathological state appears to be 
chronic ulceration of the nasal mucous membrane extending 
to the frontal sinuses, causing violent headache. " It pro- 
duces deep and extensive ulceration ; the process carried on 
mostly in the cartilages, hardly producing caries of the 
bones. It is almost a specific for perforating ulcers of the 
septum, and many cases of cure are on record." (T. F. 
Allen.) The nostrils and upper lips are excoriated, with sore 



CHRONIC CORYZA. 57 

and swollen alae, and the smell from the nostrils and mouth 
is very fetid. Kali bichromicum acts best on fat, light- 
haired people, and an additional indication is a concurrent 
affection of the digestive mucous membrane, indicated by 
foul tongue, eructations, nausea, and so forth. As to the 
dose, my experience exactly agrees with that of Dr. Hughes: 
" I recommend by way of dose the first six dilutions. The 
3d is most commonly used, except in syphilis, where the 
lowest potencies of this salt and of the neutral chromate 
have been employed with most benefit. In acute affections, 
however, I nearly always prefer the 6th, unless I give the 
I2th." 

Aurum metallicum is one of the chief remedies in chronic 
coryza, especially when the nasal bones are carious, as is 
often the case after abuse of Mercury and in syphilitic 
coryza. Still, as Dr. T. F. Allen remarks, it may also be 
called for in catarrh not yet involving the bones. The nose 
is swollen, red, inflamed and sore to the touch, especially the 
right nasal bone and adjoining parts of the upper jaw ; there 
is a discharge of greenish yellow, offensive matter. The 
pains in the bones are aggravated at night, and they are 
accompanied by flow of tears. The nostrils are ulcerated, 
crusty, agglutenated, so as to impede respiration ; ulcers in 
the nostrils covered with dry yellow crusts. The character- 
istic nasal secretion of Aurum is thick ; in the sepia coryza 
the characteristic secretion is water. Dr. Morse remarks 
that when the scrofulous diathesis is marked Aurum 
muriaticum is preferable to Aurum metallicum. One would 
hardly look for the marked mental symptoms of Aurum in 
infants, though I have observed them in young children 
associated with chronic coryza. I have always used the 
triturations from the 6th decimal to the 12th centesimal and 
with excellent results. 

Argentum nitricum is one of the leading remedies in both 
acute and chronic coryza, though Dr. T. F. Allen, an excel- 
lent authority, says that " the number of Nitrate of Silver 
catarrhs is not large." The coryza is at first dry; soon the 



58 . CHRONIC CORYZA. 

mucous membrane becomes moist, and later a thick, yellow, 
purulent mucus issues from the nostrils. The alae are pain- 
ful and swollen, the nasal bones are painful, the septum is 
studded with bleeding pimples and the nose itches violently. 

The scurfs in the nose become exceedingly painful ; if de- 
tached they bleed : bloody and purulent discharge in the 
open air, which stops in the house. The characteristic dis- 
charge is white and pus-like, mingled with clots of blood. 
The coryza is accompanied with constant chilliness, sickly 
look, lachrymation, sneezing, and violent, stupefying head- 
ache. The eyes and air passages are so frequently involved 
that Argentum nitricum does little good if the nasal pas- 
sages alone are affected. Argentum nitricum acts best in 
the dilutions from the 12th to the 30th centessimal. 

Sepia is a useful remedy in catarrhs arising from the retro- 
cession of an eruption. The nose is inflamed and swollen, 
and the nostrils are angry and ulcerated with a painful erup- 
tion on the tip of the nose. There is obstruction of the nose 
with dry coryza and loss of smell. Dryness in the choanal, 
though there is much mucus in the mouth. Discharge of 
yellowish water from the nose, with cutting pains in the 
forehead. "This remedy is permanently indicated in cases 
where there is a discharge of green, bloody mucus from the 
nose, especially when accompanied by external inflammation 
of the nose. It is curative, too, in cases where there is ulcer- 
ation high up in the nasal fossae, accompanied by loss of 
smell " (Morse). Dr. Hermann Gross remarks that in the 
Sepia coryza putrid, subjective odor predominates, while in 
the Sulphur coryza objective stench from the nose predomi- 
nates. I have used Sepia as low as the 12th centesimal, but 
have had the finest results from the 30th. 

Alumina is one of the first remedies to be considered in 
chronic dry coryza when the mucous membranes, both nasal 
and aural, are broken down by ulceration, especially in scrof- 
ulous children. Such children are often chlorotic and prone 
to obstinate constipation. The nose is red, swollen and 
painful to the touch; the nostrils are sore and scurfy; and 



CHRONIC CORYZA. 59 

the nasal mucous membrane is ulcerated, with discharge of a 
thick, yellowish mucus, or expulsion of yellowish-green scabs. 
The nose is stopped at night with dryness -of the mouth, and 
the septum is swollen and painful to the touch. The throat 
is dry, especially on waking from sleep ; the voice is thick 
and husky, and mucus accumulates in the posterior nares. 
Itching of the dorsum and of the alae is an additional indi- 
cation, and patients for whom Alumina is suitable take cold 
on the slightest exposure, yet feel better in the open air. I 
have never given Alumina lower than the 30th in this or in 
any other disease. 

Baryta carbonica is useful for the chronic coryza of chil- 
dren with enlarged glands and large abdomens, weak both in 
body and mind. The nose and upper lip are swollen, and 
the nostrils are very dry with frequent sneezing. The Baryta 
carbonica coryza, however, is predominantly fluent — the di- 
rect opposite of Silicia — and the discharge is thick, yellowish 
and profuse. I have noted that Baryta carbonica is of little 
use unless the external nose is involved in the malady. This 
remedy has always been given by me in the 6th decimal trit- 
uration, and I have seen excellent results from it. 

Lycopodium is one of the most reliable of our remedies 
for the dry form of chronic coryza, with much sneezing 
during the day ; at night the nose is completely stopped, 
with dryness of the nose and burning headache. The nose 
is obstructed high up, with almost complete closure of the 
nostrils at night, so much so that the patient breathes with 
open mouth and protruding tongue. The morbid action 
frequently extends to the frontal sinuses, with frontal head- 
ache and thick, yellow discharge, which is at the same time, 
acrid and excoriating. The irritation is prone to extend to 
the air-passages, causing cough with loose expectoration, and 
the coryza then becomes somewhat fluent. This remedy is 
suitable for children who take cold easily, and who are 
troubled with derangement of the alimentary tract, and of 
this derangement the production of flatus is the most prom- 
inent symptom. Lycopodium is a most important agent 



60 CHRONIC CORYZA. 

when chronic coryza has extended to the air-passages, taking 
an ulcerative action and simulating pulmonary consumption. 
The remedy acts best in the 30th dilution, and seems to be 
of but little value below the 12th centesimal. 

Lachesis is used in chronic coryza of the severest kind, 
syphilitic and mercurial as well as the still worse mercurio- 
syphilitic. The leading indication for Lachesis is a profuse 
watery running from the nose, accompanied by great sore- 
ness and swelling. The mucous membrane of the nose is 
swollen and bluish, and the nostrils are raw and bleed easily. 
The nose is full of scabs, and the discharge is pus mingled 
with blood, or there may be an extremely copious discharge 
of watery mucus. At the same time, the throat inclines to 
a low grade of inflammation resulting in plastic exudation, 
and the glands of the neck are swollen and tender. Epis- 
taxis occasionally appears, and all the symptoms are worse in 
the afternoon and after sleeping. Lachesis acts well in all 
the dilutions from the 12th to the 200th ; I. have mostly used 
the 30th. 

Graphites is suitable for children of lymphatic tempera- 
ment who are subject to herpetic eruptions of the skin. Con- 
stipation is frequently present, and the patients easily take 
cold if exposed to a draught of air. Catarrh with obstruc- 
tion of the nose ; severe stuffed catarrh, with much nausea 
and headache, without vomiting; fluent coryza, with frequent 
sneezing, with pains in the sub-maxillary glands ; heat in the 
forehead and face. Dryness of the nostrils, or alternate 
flowing and dryness ; dry scabs with sore or cracked and 
ulcerated nostrils; bloody mucus from the nose, alternating 
with expulsion of dry scurfs; discharge of thick, fetid mucus. 
This remedy has usually been given in the 12th dilution, but 
I have had the best results from the 30th. 

Kali carbonica is suitable for anaemic children of cachetic 
appearance, with puffy swelling over the upper eyelids, espe- 
cially in the morning. Obstruction in the nasal passages, 
making it impossible to breathe through the nostrils when in 
a warm room ; the patient, however, can breathe through the 



CHRONIC CORYZA. 6 1 

nostrils in the open air. The external nose is red and swollen 
with sore, crusty nostrils, or the nostrils are raw and 
bleeding. Fetid, yellow-green discharge from the nostrils ; 
according to Hughes the characteristic discharge, is profuse 
and thin. The 30th dilution is most used, though good 
cures have been effected with the 12th centesimal dilution. 

Kali hydriodicum is a principal remedy in chronic coryza 
of the nasal passages and frontal sinuses when occurring in 
syphilitic children, or in those poisoned with mercury. 
Ulceration of the internal nose, involving the frontal sinuses 
and antrum highmore ; the nose is red and swollen with con- 
stant discharge of acrid, watery, colorless liquid, with violent 
lachrymation ; anxious expression and restlessness ; discharge 
of burning, corroding matter from the nose ; the inflamma- 
tion extends into the eyes and there is much conjunctivitis ; 
the characteristic discharge is copious and watery, but it does 
not excoriate. I have always given this remedy in material 
doses, never higher than the 3d decimal dilution. 

Nitric Acid is, according to Dr. T. F. Allen, a very potent 
remedy in syphilitic catarrhs of the nose and throat, also 
when such cases are complicated with mercurial poisoning. 
" I have derived more real satisfaction in seeing the prompt 
and lasting effects of this drug, not only in syphilitic catarrhs 
but lichen, ulcers, glandular affections, falling of the hair, 
etc., etc., than from anyother remedy. I think it is oftener 
indicated than any other, especially before the bones become 
much affected. I have occasion to use it every day in dis- 
pensary practice, and invariably the report is great improve- 
ment. The malar bones become sore and painful ; soreness 
and bleeding of the inner nose ; the nostrils are ulcerated, 
blood and bloody matter are blown out of them, with un- 
pleasant smell. Nasal mucus goes down into the throat ; in- 
flamed and swollen alae nasi, acrid matter from the nose at 
night ; discharge of thick nasal mucus, corroding the nostrils ; 
severe catarrh, with swelling of the upper lips and especially, 
night cough ; stuffed catarrh with dryness of the throat on 
empty swallowing. I have never used Nitric acid higher than 



62 CHRONIC CORYZA. 

the 1 2th centesimal, though it would certainly act well in 
much higher dilutions. 

Cyclamen Europaeum is highly recommended in chronic 
coryza when the patient sneezes a good deal with profuse 
discharge, and rheumatic pains in the head and ears. " I had 
a fine illustration of the curative powers of Cyclamen in such 
cases with my colleague, Malaise, in Liege ; the patient was 
a lady of upwards of sixty years old, and had been suffering 
from catarrh for years ; it disappeared in less than twenty- 
four hours, to the astonishment of everybody " (Jahr). 

Other remedies are Hepar sulphuris in scrofulous cases 
where there is great sensitiveness and the patient is chilled 
by the slightest draft of air — also in cases in which Mercury 
has been abused ; the nose is swollen and painful, like a boil, 
and the nasal bones are painful to the touch, the discharges 
are thick and pus-like, and sometimes tinged with blood. 
Iodium for chronic coryza in cachectic, emaciated children of 
scrofulous habit with enlarged and indurated glands ; the 
nose is painful and swollen, with fetid secretions which at 
times become a clear and continuous stream. Mercurius 
iodatus for syphilitic and scrofulous children with induration 
and swelling of the glands ; the nasal bones are inflamed and 
the nostrils are sore and crusty ; the nasal discharge is a 
tough, white or yellowish mucus which forms mostly about 
the posterior nares and adjoining parts ; profuse, acrid, long- 
lasting discharges which excoriate the nostrils and upper lip 
Arsenicum iodatum, when the little patient has the tubercu- 
lar diathesis with alternate chills and heat of the body ; 
discharge of very irritating, watery mucus, corrosive 
and copious ; at times this discharge is scanty and 
thick, sometimes it is tenacious and frothy. Stannum 
metallicum for severe catarrh with copious expectora- 
tion of thick, gray-green mucus, mixed with blood. Anti- 
monium crudum, when the external nose is sore and 
painful, the nostrils angry, puffy and crusty, with a discharge 
of thick yellow mucus. Hydrastis for ozsena with bloody, 
purulent discharge, or chronic coryza with thick, tenacious 



CHRONIC CORYZA. 63 

secretions, more from the posterior nares, dropping down in- 
to the throat. Ailanthus for coryza, with rawness inside the 
nostrils ; chronic nasal catarrh, with difficult breathing 
through the nostrils ; the whole nose and upper lip covered 
with very thick, grayish-brown scabs. Asafcetida for pains in 
the bones of the nose, with a greenish offensive discharge, 
worse at night. Berberis, for chronic coryza of the left side, 
extending into the antrum of Highmore, with purulent yel- 
low or greenish discharges. 

Additional remedies are Ammonium carbonium, Ammo- 
nium muriaticum, Natrum carbonium, Natrum muriaticum 
and Magnesia muriatica. 

Aphorisms. 

1. Chronic coryza of infants is common, but it is ex- 
ceedingly difficult of cure. 

2. The best means of preventing chronic coryza is to at- 
tend to all cases of acute coryza, even those which seem to 
be insignificant. 

3. Chronic coryza has little or no tendency to cure itself, 
the earlier the patient is attended to, the more rapid will be 
the cure. 



CHAPTER IV. 



Spasm of the Glottis. 



Few diseases have received so many names as spasm of 
the glottis, and in this case, as in many others, " words 
without knowledge darken counsel," and, to use the forcible 
language of John Fletcher, "the alliance between nosology 
and nonsense is too palpable to escape the meanest capacity." 
It has been called " inward fits " by the vulgar, as if the word 
"inward" conveyed the slightest idea of the locality of the 
disease, though Trosseau and Pidoux, who style it "internal 
convulsions," almost sanction the name. With equal incor- 
rectness it has been styled "goitre of infants," "suffocative 
catarrh" and "laryngeal asthma." Millar, who claims to 
have been its first observer, calls it after himself, and Kopp, 
who claims the same distinguished honor, does the same 
thing. Boerhaave styles it "asthma puerorum ;" Hufeland 
calls it " catalepsis pulmonum," and Pagenstecher " asthma 
dentientium." It has been called " false croup," " cerebral 
croup" and "spasmodic croup," and Dr. Marshall Hall calls 
it "croup-like convulsions." Bouchut names it "phreno- 
glottism," Eberle makes one smile with " carpo-pedal 
spasms," and Mason Good, whose system of nomenclature 
is incomparably the most complicated we possess, calls it 
" laryngismus stridulus," which, however, seems likely to be 
the classic title of the disease. It has no affinity to asthma, 
croup or catarrh, and I shall use the familiar name of spasm 
of the glottis which conveys some definite idea to the mind, 
and which is sanctioned by some of the best of the French 
writers who speak of " spasme de la glotte." 

Spasm of the glottis may be defined to be a spasmodic 



SPASM OF THE GLOTTIS. 65 

contraction of the muscles which narrow the glottis — namely, 
the two thyro-arytenoid, two lateral crico-arytenoid, and the 
arytaenoideus muscles — and this narrowing' of the glottis is 
accompanied in very severe cases by spasmodic action of the 
diaphragm and intercostal muscles. As a result there is a 
succession of crowing, stridulous inspirations with a feeling 
of suffocation in the larynx, commencing suddenly, lasting 
at first for a brief period, and ceasing suddenly, usually with 
a fit of crying. The attack is unaccompanied by cough or 
any other evidence of laryngeal or thoracic disease, and as 
the disease advances other convulsive symptoms appear — 
strabismas distortion of the face and general convulsions, 
and peculiar convulsions of the hands and feet mark the 
more advanced stages. Should the two posterior crico- 
arytenoid muscles be affected, the very first attack would 
necessarily result in complete cessation of respiration and 
consequent death. 

The most discordant views have'prevailed as to the nature 
of this disease. Etmuller, who wrote in 1697, speaks of the 
"suffocative convulsions of infants" arising either from 
spasm of the muscles closing the glottis or paralysis of those 
opening it. Richa and Verdries, in the beginning of the 
eighteenth century, thought it was a laryngeal cramp caused 
by swelling of the thymus gland. In 1769, John Millar wrote 
on the disease, but as he confounded it with catarrhal laryn- 
gitis, and possibly with diphtheritic croup, we merely gather 
that he writes of laryngeal diseases running their course with 
attacks of suffocation and often ending in death. In 1795, 
Wichmann defined the disease to be a non-inflammatory form 
of croup — a purely nervous affection — without alteration of 
the mucous membrane. In 1830, Kopp published his well- 
known work in which for the first time he endeavored to 
give an anatomical basis to the etiology of this disease. The 
cause, according to this writer, is always hypertrophy of the 
thymus gland compressing the nerves supplied to the larynx, 
and this view was very generally held by medical writers for 
a number of years. In 1836, Ley announced that the disease 



66 SPASM OF THE GLOTTIS. 

arose from the pressure of enlarged glands on the pneumo- 
gastric or recurrent nerves causing paralysis of the abductors 
of the larynx. Rilhet and Barthez, and indeed most of the 
French writers, vaguely describe it as being a " neurosis," 
while Valleix doubts the propriety of classing it as a distinct 
disease. In 1841, Marshall Hall, in his famous work, "The 
Nervous System/' referred this disease in all cases to reflex 
causes. " It is excitation of the true spinal or excito-motory 
system. It originated in — 

I. — 1. The trifacial in teething. 

2. The pnenmogastric in over- or improperly-fed 

infants. 

3. The spinal nerves in constipation, intestinal disor- 

der, or catharsis. These act through the me- 
dium of 
II. — The spinal marrow, and 
III. — 1. The inferior or recurrent laryngeal, the constrictor 
of the larynx. 
2. The intercostals and diaphragmatic, the motors of 
respiration." 
Two years later, Elsasser announced his notable discovery 
of the connection between rachitis and spasm of the glottis, 
though he erred in attributing the latter always to pressure 
on the brain when the child lay on its back. In 1852, Bednar 
published the results of thirty-nine post-mortem examinations 
of children who had suffered from enlarged thymus glands, 
of which number but fifteen had suffered from spasm of the 
glottis during life, concluding that the disease did not depend 
upon thymic hypertrophy. In 1858, Bednar's observations 
were strongly confirmed by Friedleben, in spite of which 
Abelin, in 1868, maintained the old view, that spasm of the 
glottis often has its origin in swelling of the thymus gland, 
professing to ground the opinion on his post-mortem exami- 
nations. Professor George B. Wood attributes it to a 
" general morbid excitability of the nervous system, directed 
especially to the muscles of the glottis," and Dr. P. W. Bird 
considers that " it is not an independent disease, but merely 



SPASM OF THE GLOTTIS. 6j 

a collection of symptoms consequent on disturbance of the 
nervous system in general, and of the respiratory nerves in 
particular." Later, Sir Dominic Corrigan stated the opinion 
that the disease was caused by a material change in the 
cervical position of the spinal cord, and Dr. Charles West 
maintains that it is often caused by the irritation of teething. 
Several distinct influences are concerned in the production 
of this disease, and upon a proper appreciation of these 
influences successful treatment will depend. Many cases, as 
Dr. John Clarke long ago pointed out, depend upon an 
irritation of the brain, and this irritation is most likely the 
result of a local congestion near the origin of the pneumo- 
gastric nerve. In support of this view which is fast gaining 
ground, we have the undoubted fact that many cases of 
spasm of the glottis are preceded by well-marked symptoms 
of cerebral disease ; and in cases of disease of the medulla 
oblongata external pressure has been known to cause the 
disease. It is well to remember, however, that the morbid 
appearances seen after death are frequently not the cause of 
the spasm of the glottis, but the result of the -sudden apncea. 
Many cases depend upon a rachitic condition of the bones 
of the skull — the " craniotabes " of Elsasser. Sir William 
Jenner noticed that rickets existed in every case of spasm of 
the glottis that he saw, save only two cases, and in ninety- 
six cases of spasm of the glottis examined by Lederer, 
rachitic softening of the cranial bones existed in ninety-two. 
In this class of cases there are probably changes in the nutri- 
tion of the brain as one result of the rachitic dyscrasia, and 
the spasm of the glottis is caused by the reflex influence of 
the morbid change in the cerebral mass. Strumous disease 
of the cervical and bronchial glands may cause spasm of the 
abductors of the larynx, which is the essence of the disease 
under consideration, by obstructing the venous circulation in 
the neck, and thus giving rise to irritation of the brain, which 
is again reflected upon the laryngeal muscles. Again, some 
medical writers distinguish an acute and a chronic form of 
spasm of the glottis ; the acute form comprising the cases in 



68 SPASM OF THE GLOTTIS. 

which the spasms recur frequently, and in which death by 
suffocation often occurs after a few paroxysms ; the chronic, 
those which have few paroxysms at comparatively long 
intervals.' 

Spasm of the glottis is a disease of northern climates and 
of the winter season ; and the mild air of summer is a most 
powerful adjuvant in the cure. Out of forty-one cases 
Henoch noticed thirteen in the month of March, and Dr. 
Gee confirms these observations, for of 65 cases observed, 58 
were in the first half of the year and only 5 in the second 
six months. The following figures show the number of 
these cases occurring in each month : January, 3, February, 
11, March, 7, April, 13, May, 16, June, 8 (total 58) ; July, o, 
August, 1, September, o, October, 1, November 1, Decem- 
ber, 2 (total, 5). Gee and Flesch simultaneously advanced 
the theory that the increased susceptibility to the disease is 
to be attributed to the exalted nervous condition of the 
children, resulting from the long confinement indoors. It 
seems to be rare in France, for when Rilhet and Barther 
published their first edition they had seen but one case, and 
they were acquainted with but one other, published by 
Constant in the Bulletin de Thcrapeutique ; when they issued 
the second edition of their work they had seen only nine 
cases in all. It is more common in Germany, and still more 
common in Great Britain, for, during the twenty years from 
1857 to 1876 inclusive, the Registrar-General reports 7,318 
deaths under ten years of age, and 37 deaths from ten to 
seventy-five years of age. Dr. Copland says that he has had 
as many as three cases under treatment at the same time ; 
Ley reports having met with over twenty cases ; and Dr. 
Charles West mentions thirty-seven of which he has pre- 
served some record. Dr. Marshall Hall observes that "with- 
in the short space of one month I have seen five cases of 
croup-like convulsions." Dr. Condie speaks of it as being 
common in the United States, while Dr. J. F. Meigs re- 
marks: " I do not think it is a common disease in Philadel- 
phia, though it is certainly not extremely rare, since I have 



SPASM OF THE GLOTTIS. 69 

seen four cases myself and know of the occurrence of two 
other cases that proved fatal, and of two cases of recovery." 
The writer, whose practice is largely among children, has 
treated twenty-eight cases and has heard of many more in 
the practice of his medical friends. 

Spasm of the glottis is, as a general rule, a disease of the 
first dentition, though the writer lately had a case in which 
the patient was five years old, and Meigs and Pepper remark 
that they had one very rare case in which the patient was 
seven years of age. The English Registrar-General, how- 
ever, a few years ago reported 3 cases in which the patient 
was no less than seventy-five years old. Vogel remarks that 
the disease makes its appearance with the eruption of the 
first tooth and disappears with that of the last, adding that 
it occurs much oftener with the cutting of the incisor teeth, 
in the first half year of life, than with that of the canine and 
molar teeth. Gerhard assigns for this disease the period 
between the fifth and twenty-fourth month, and he says it 
is very rare after dentition terminates. Romberg relates 
that one of his own children was attacked with violent 
spasm of the glottis on the second day after birth, but it 
only occurred in a single paroxysm and did not return ; and 
this distinguished writer thinks that the chief proclivity to 
this disease is manifested from the sixth to the fourteenth 
month, children of three or four years being exceptions. 
Heines says that of 226 cases which he attended, 174 were 
in the first year of life and the remaining 52 between the 
second and third years. Rilliet and Barthez, whose experi- 
ence was but limited, observed this disease- almost exclusive- 
ly in infants of the age of three weeks to a year and a half, 
and Flesch states that it is rare after the twenty-first month. 
Heffen remarks that the disease is rare before the close of 
the fourth month, and he thinks that the majority of cases 
occur between the age of four months and the close of the 
second year ; but if the disease is not developed till during 
the second year and is disposed to be tedious, it may last for 
a longer or shorter period beyond the limit named. He has 



yo SPASM OF THE GLOTTIS. 

further noted that if it occurs after the close of the third 
year it is less intense than during the first years of life, and 
he instances a mild case lately seen in a boy eight years of 
age. Of thirty cases taken indifferently from the practice of 
Drs. Meigs and Pepper and from various authors, 13 were 
six months or less of age, 1 1 between six months and a 
year, 4 between one and two years of age, 1 of two and 1 of 4 
years of age ; so that of these thirty cases four-fifths were un- 
der one year. In Morell McKenzie's 31 cases the ages at 
which the attacks occurred were as follows: from birth 1 case, 
at 4 months 1 case, at 5 months 6 cases, at 6 months 5 cases, at 
7 months 7cases, at 9 months 3 cases, at 10 months 1 case, at 
1 1 month 2 cases, at fifteen months 3 cases, at seventeen 
months 1 case, and at 23 months 1 case. In 31 out of 37 cases 
observed by Dr. Charles West the disease occurred between 
the age of six months and two years ; and in 48 cases Dr. 
Gee found 1 at six months, 19 from six to twelve months, 16 
from twelve to eighteen months, and 12 from eighteen 
months to two years. Henoch saw sixty-nine children with 
spasm of the glottis, and 39 were between the ninth and 
thirtieth months, and 22 between the second and ninth 
months, and Salathe saw 24 cases, 4 in newly-born infants, 
9 in those of from one to six months old, 6 in those from 
six to twelve months old, 4 from one to three years, one in 
a child twelve years old. Wunderlich thinks that the 
chronic form mostly occurs between the fourth and tenth 
months, and the acute form from the age of eighteen months 
to nine years ; and Herard has an almost unique experience, 
for all his patients were over two years of ,age, and two of 
them were between three and four years old. Of the writer's 
28 cases, eleven were less than six months, sixteen between 
six months and a year, and one was five years. 

The following tables compiled from the English Registrar- 
General's Reports by Dr. Morell Mackenzie, showing the 
number of deaths, for the twenty years from 1857 to 1876 
inclusive, from the disease occurring at different ages, gives 
the most conclusive evidence as to the importance of age as 
a predisposing cause. 



SPASM OF THE GLOTTIS. 



71 



Analysis of the English Registrar-General's Reports on 
the Mortality from Spasm of the Glottis : 

CHILDREN UNDER 10 YEARS OF AGE. 





Totals 






Years of Age. 






Under 

1 
Year. 


T. 


2. ' 3- 


4- 


From 
5 to 10 
Years. 


Females 

Males 


2,547 
4,77i 


1,487 
2,915 


69I 
1,305 


152 94 
213 97 


60 
63 

123 


63 

8S 


Grand Total 


7,3i8 


4,402 


2,086 


365 i I9 1 


151 



ADULTS. 





Totals 


Years of Age. 




TO 


15 

1 


20 

1 
2 


2 
2 


35 

2 
2 


45 

1 
3 

4 


55 

1 

1 


65 

1 
4 

5 


75 


Females 

Males 


13 
24 


5 

7 


3 




Grand Total 


37 


12 


1 


3 


4 


4 


3 



After #£? comes .^.r as a most influential, predisposing 
cause in this disease. The Registrar-General's Report just 
quoted gives 2,547 females against 4,771 males in the first 
table, and in the second, which speaks of persons from 10 to 
75 years of age, the numbers were 13 females to 24 males. 
Of the 16 cases seen by Herard and Rilhet and Bartlez, 12 
occurred in boys and 4 in girls, while of 183 collected by 
Larent, in which the sex was noted, 125 occurred in boys 
and 58 in girls. In Steiner's 226 cases the relative propor- 
tion of the sexes was 150 boys to j6 girls, while Vogel in his 
15 cases had 11 boys against 4 girls. Of the 28 cases under 
my own care, 19 were boys and 9 were girls. Of Mackenzie's 
37 patients, 21 were boys and 16 girls, while in Dr. Gee's 48 
cases, 34 were boys and 14 girls. Almost the only statistics 
in contradiction to these are furnished by Salathe, who found 
only eleven boys in twenty-four cases, while of 297 cases 
seen at the hospital for sick children, London, 166 were 
males, and 131 females, making a total of 177 males, 



72 SPASM OF THE GLOTTIS. 

and 144 females ; but these observations are too isolat- 
ed and the numbers too few to invalidate the very conclu- 
sive figures already given. Steffen gives the following table, 
which " alone amounts to a demonstration/' though the 
Registrar-General's figures being larger are still more con- 
clusive : 

girls. 



Herard 


saw 16 cases, 


12 


being 


boys 


and 4 


Larent 


« 183 " 


125 


" 


" 


" 58 


Steiner 


" 226 


150 






' 76 


Henoch 


" 61 


49 






" 12 


Werner 


'•■ 26 '• 


15 




■' 


" II 


Hachmann 


" .14 " 


12 


" 




2 


Pagensticher 


18 " 


14 




" 


'" 4 


Kopp 


10 


9 


■ ' 




1 



554 336 168 

The precise cause of this greater predisposition of the 
male sex to spasm of the glottis is still an unsolved mystery. 

Still another predisposing cause of spasm of the glottis is 
supposed to be heredity. Romberg says that in one family 
he attended two children who labored under this complaint 
(one of whom died), after three other children of the same 
family had fallen victims to it ; and Gerhardt reports a fam- 
ily of nine, all of whom suffered from spasm of the glottis, 
and seven of these died. Dr. Ley quotes four instances 
from various authors in which three children in each family 
had the disease, and Powell saw one family of thirteen chil- 
dren, all of whom had had attacks of this malady. Werner 
saw two cases each in four families, and three children in 
another family seized one after another, and two of the 
writer's children have had severe attacks, but neither died. 
But the most striking illustration of this phase of the disease 
is that given by Reid, in which, out of a family of thirteen 
children, ten died of the disease and only one escaped an 
attack. 

Do these cases prove an actual hereditary descent from 
parent to child ? Romberg, a great authority on nervous 



SPASM OF THE GLOTTIS. 73 

diseases, is quite certain that it does, for he says : " There 
can be no doubt of the existence of an hereditary disposi- 
tion ; in many families several and even all the children, 
though they may have been differently brought up, both as 
to residence and food are attacked with a spasm of the 
glottis.'' Bouchert remarks that " it is sometimes observed 
amongst children born of a delicate, excitable, or nervous 
mother ; and what is a strong proof of the original disposi- 
tion of this disease is its successive appearance amongst all 
the children of the same family ;" and Vogel, after observ- 
ing that " the hereditary character of spasm of the glottis 
is interesting," goes on to say that "the mothers of the 
children whom I have treated for this disease were all of a 
tolerably excitable nature, and often complicated the child's 
disease by indulging in their habitual hysterical outbreaks." 
Morell Mackenzie thinks that the many cases in which the 
disease has attacked large families do not really prove its 
actual hereditary descent, but that they " strongly point to 
consanguineous influence ; and he points out that the appar- 
ently strong proof afforded by the cases of Gerhardt and 
Reid may all be explained on the supposition that in each 
instance all the children were exposed to the same anti- 
hygienic influences. He illustrates this view of the question 
by the following case : " A gentleman of slightly strumous 
organization married a healthy woman, and had two boys 
and two girls. They none of them suffered from laryngis- 
mus, but the influence of the father's constitution was shown 
in the children by enlarged cervical glands, hypertrophied 
tonsils and early decay of the teeth. The family grew up, 
all married and all had children. In two of the families one 
child had laryngismus, and in one family two children suf- 
fered from the disease, and in one family three children 
were affected. In all four families the children were slightly 
rickety." Steffen correctly points out that all the cases 
which have been adduced to prove a real hereditary predis- 
position to this disease do not prove a true descent from 
parent to child, but only that several children of a family 



74 SPASM OF THE GLOTTIS. 

suffered from it — which is a very different thing. So that 
till descent from parent to child is clearly proved, we must 
conclude that the spasm of the glottis is not hereditary. 

The prevailing opinion of those authors who have devoted 
most time to the investigation of this disease is that children 
subject to it are mostly delicate and feeble, and that it 
affects most violently those of scrofulous and rachitic con- 
stitution. On the other hand it has often been observed in 
children of the most robust and vigorous constitution, and 
some of the writer's patients were pictures of health. The 
proportion of children who suffer from both spasm of the 
glottis and rickets is undoubtedly very large, and Steffen, 
writing from European observations, is probably correct in 
asserting that the healthy constitution of the body which 
presents favorable soil for the commencement of the disease 
consists in, by far, the larger number of cases in a predispo- 
sition to rachitis. Dr. Gee reports rickets present in 48 out 
of his 50 cases, all of which, however, occurred among 
the poor, in whom all the causes of rickets would most likely 
be in full operation ; Flesth says that three-fourths of his 
cases were rickety, and of Mackenzie's 31 cases, all of which 
occurred in private practice ; 17 were slightly rachitic, while 
2 were markedly rachitic. Steffen asserts that in by far the 
larger number of cases, say at least nine-tenths, rickets give 
rise to spasm of the glottis. But one of the writer's 28 cases 
suffered in any degree from rickets, and that one case only 
to a very small extent ; and it is quite certain that on the 
North American continent the co-existence of rickets and 
spasm of the glottis is much rarer than in Europe, where, in 
a very large proportion of the population, the causes of 
rachitis are more actively at work than they are on this more 
favored continent. Elsasser looked upon craniotabes, which 
only appears in well developed rachitis, as being almost 
always the cause of spasm of the glottis ; but, though Steffen 
says that " spasm of the glottis may be expected when it 
(craniotabes) is present," the writer has never noted cranio- 
tabes and spasm of the glottis occurring in the same patient, 



SPASM OF THE GLOTTIS. 75 

though he has seen 28 cases of the latter in his own practice 
and many more in the practice of others. Again, he has 
seen a large number of cases of craniotabes, none of which 
had ever suffered from spasm of the glottis, so that he looks 
upon the connection between the two morbid states as being 
at least problematical. Condie thinks that " it is very cer- 
tain that, after the most careful analysis of the observations 
on record in reference to rachital softening of the cranium, 
that in the majority of instances, spasm of the glottis occurs 
in cases where not a trace of craniotabes exists." Curiously 
enough, Steffen himself admits that spasm of the glottis " in 
no way depends on it (craniotabes), and does not necessarily 
follow ; " and Mackenzie, while admitting that the two 
morbid states often co-exist, says that " it does not follow 
that rachitis is to be regarded as the cause of laryngismus." 
On the other hand, Vogel, a great authority, considers that 
the connection between craniotabes and spasm of the glottis 
has been " satisfactorily demonstrated " by Elsasser, but 
he differs from Elsasser as to the precise modus operandi. 
Elsasser held that the pressure of the pillow on the soft 
occiput was competent to cause spasm of the glottis, while 
Vogel contends that " not the softness and depressibility of 
the occiput per se, but their effects, should be regarded as 
the exciting causes, as the meninges may thereby degener- 
erate into an abnormally congested condition." 

More influential than craniotabes in the causation of 
spasm of the glottis is rachitis of the bones of the thorax. 
Children who are born or brought up in a small, or damp, or 
cold house, who live in close or unwholesome air, who are 
badly or insufficiently nourished, and, above all, who are 
deprived of sunshine, are apt to suffer from disorder of the 
processes of digestion and assimilation, and in these unfor- 
tunate children rachitis is developed with melancholy facility 
— even in those whose parents had not suffered from 
rachitis in their childhood. Steffen, in his ingenious explana- 
tion, points out that an abnormal irritability of the nervous 
system is one of the most marked features of spasm of the 



j6 SPASM OF THE GLOTTIS. 

glottis. This abnormal irritability is greatly increased, if 
not entirely caused, by the rachitic state in the following 
manner : the lateral flattening of the walls of the thorax 
leads to a marked diminution of the capacity of the chest, 
and that, in its turn, leads to a more superficial respiration, 
and thence to increased frequency of respiration ; this, of 
course, at once necessitates an increased activity of the 
heart, greater wear and tear of the system, and consequent 
irritation of the brain and entire nervous system. Suddenly 
then, in such children, spasm of the glottis occurs, and in 
these cases it is not so inuch the bones that are at fault as 
the deep-seated disturbance of nutrition and, above all, the 
greatly increased irritability of the nervous system, without 
which spasm of the glottis is unlikely to take place. 

Many excellent observers held to the purely nervous nature 
of spasm of the glottis. Mason Good asserts that it is 
"purely and idiopathically nervous," and Gregory says " it is 
caused by a high degree of irritability in the nervous system 
of the child." Felix von Niemeyer holds that "it depends 
upon a morbid excitement of the nerves by means of which 
contraction of the muscles of the glottis is effected," adding 
"that by uniform shortening of all the muscles at once, the 
vocal chords become tightly stretched, and the glottis is 
closed." But he considers that this irritation may be due to 
pressure along some part of the course of one of these nerves, 
or to centric irritation of the root of the vagus. Scrofula 
of the tracheal and bronchial glands is present in a consid- 
erable proportion of cases of spasm of the glottis, and these 
swollen glands probably act by pressing on the recurrent 
nerves. If this pressure is continuous, a constant wheezing 
is present, but usually the pressure, depending on the amount 
of blood in the glands, is moderate and variable, so that 
respiration is sufficiently easy. In most of these glandular 
cases the bones of the thorax are affected at the same time, 
and here Steffen's ingenious explanation would hold good. 
Finally, all experienced observers will concur in the opinion 
of the lamented Felix von Niemeyer, "In most cases the 
pathogeny of this disease is obscure." 



SPASM OF THE GLOTTIS. JJ 

The exciting causes are very various. In general terms it 
may be said that any force capable of acting upon the 
general morbid excitability of the nervous system will 
produce the disease in those predisposed to it. The irrita- 
tion of teething stands in the front rank, though Morell 
Mackenzie thinks that the influence of teething in the 
causation of spasm of the glottis is " enormously over-rated,'' 
an opinion in which the author cannot concur. Spasm of 
the glottis is rarely the first manifestation of morbid 
dentition, it is usually preceded by irritation of the brain, or 
disorder of the alimentary canal. Sometimes a child has an 
attack of spasm of the glottis whenever it cuts a tooth, but 
the first of these attacks is usually the most severe. Dis- 
orders of digestion are also a frequent cause, and hence it 
often occurs in children fed by hand. Weaning, according 
to Romberg, appears to favor the development and continu- 
ation of the disease. Sometimes it depends upon habitual 
constipation, and it may be caused by the sudden suppression 
of the diarrhoea of dentition. No single agency occupies a 
more prominent position in the popular pathology than 
"worms," and this omnipresent cause is capable of exciting 
an attack of spasm of the glottis in those predisposed to it. 
The disease, again, may depend upon some deep-seated 
cerebral affection, and two of the writer's most severe cases 
were caused by congestion of the base of the brain. It may 
precede hydrocephalus, and its occurrence in a child who is 
not teething and who is free from disorders of the digestive 
system, is always a suspicious circumstance. The mere act 
of swallowing occasionally excites an attack, and Prof. G. B. 
Wood says that infants are sometimes attacked with it when 
tossed playfully in the air. The writer has seen it follow 
infantile emotions as fretting and fright, and in such cases 
the disease is very liable to recur. 

The briefest and, at the same time, the most graphic 
account of the disease is that given by Dr. John Clarke in 
his "Commentaries on the Diseases of Children/' "The 
child is suddenly seized with a spasmodic inspiration, 



78 SPASM OF THE GLOTTIS. 

consisting of distinct attempts to fill the chest, between 
each of which a squeaking noise is often heard. The eyes 
stare, and the child is evidently in great distress; the face 
and the extremities, if the paroxysm continue long, become 
purple ; the head is thrown backward, and the spine is often 
bent as in opisthotonos, at length a strong expiration takes 
place, a fit of crying generally succeeds, and the child, 
evidently much exhausted, generally falls asleep." 

Spasm of the glottis often appears suddenly and wholly 
without warning, though the little one has sometimes been 
drooping for a few days, has lost appetite, and has been 
fretful and peevish. The lighter attacks merely consist in 
crowing inspiration, and this excites little or no alarm. If 
the attack takes place during the day the little one becomes 
pale, throws itself backward, and moves the hands and feet 
uneasily. Suddenly the crowing inspiration appears, the eyes 
roll up in the head, and the thumbs are turned in but not 
clenched tightly. At once the child cries out, and the attack, 
which had lasted but a few moments, is over. The little one 
is cross for a while, but soon regains it equanimity. If these 
light attacks occur in the night time the child wakes up, has 
the attack and then falls asleep, and unless the mother 
chances to be awake the disease may go on unnoticed for 
quite a time. 

In severer cases the first attack is apt to take place at 
night — though Steffen says this is an error — very often 
towards midnight when, after the first deep sleep has passed 
away, the child suddenly starts up with great difficulty of 
breathing, inspiration being accompanied by a shrill crowing 
noise, which some observers compare to that of croup, but 
which really differs very much from it. The patient becomes 
much alarmed, and indeed the paroxysm is of the most 
urgent nature, and real danger is present. A few crowing 
inspirations take place, or, more rarely, some very laborious 
and audible expirations resembling a paroxysm of emphyse- 
matous breathing. Suddenly a more or less complete closure 
of the glottis takes place, the crowing sound ceases, the 



SPASM OF THE GLOTTIS. 79 

respiratory movements of the chest are arrested, and the 
thorax, the diaphragm, and even the anterior abdominal 
muscles become fixed and immovable. The crowing inspira- 
tions which precede the glottis seizure are usually accompa- 
nied by a flushed countenance, but the face now becomes 
pale and livid, and, if the paroxysm lasts long, this deepens 
into a cyanotic hue. The child throws its head back, the 
eyes roll in the head or stare straight forward, the great 
vessels of the neck become turgid, the mouth opens and the 
nostrils dilate, and a cold sweat suffuses the forehead and 
even the entire head. 

In many instances general convulsions appear, especially 
if the paroxysm is severe and of long duration. All the 
muscles of the arms and legs are affected, the hands are 
tightly closed and the thumbs pressed into the palm, and at 
times even the wrists are bent inwards. Sometimes the 
hands are tumefied and reddened, and in almost all cases 
pain is caused by an attempt at extension. The spasm also 
affects the feet, the great toe is drawn apart from the other 
toes which are bent inwards, and the foot is rigidly extended, 
or, as in a recent case of the writer's, fixed in the form of 
talipes varus. These so-called " carpo-pedal " contractions 
are most likely accompanied by great pain. The general 
convulsions, even the episthotonos, evidently depend upon 
the convulsions of the glottis, for they appear and disappear 
with them, and the more exquisite forms partake of the 
character of epilepsy. Frequently the fceces, less frequently 
the urine, are passed involuntarily during the attack. The 
paroxysm terminates with one or more whistling inspirations, 
and the respiration, at first very irregular, assumes its 
accustomed rhythm, consciousness returns, the action of the 
heart becomes stronger and more regular, the cyanotic hue 
of the face gives place to pallor which, in its turn, gives way 
to the normal color, and the child is itself again. 

In some cases, happily rare, the paroxysm assumes the 
form of a sudden spasm, almost without sound, which does 
not relax till the child is dead. These are the cases in which 
the posterior crico-arytenoid muscles are most likely affected. 



8o SPASM OF THE GLOTTIS. 

Morell Mackenzie says that " the first attack of laryngis- 
mus often comes on at night — frequently towards eleven or 
twelve o'clock ; " but Steffen asserts that " the supposition 
that spasm of the glottis has a special predeliction for the 
night season is an error held by very many." Amongst that 
many must be included the present writer, for a very large 
majority of his cases had the first attack in the night season, 
and most of the subsequent paroxysms occurred during the 
night. An attack is very short, say from five seconds to 
two minutes, though the extreme danger makes the time 
seem much longer, and attacks said to last half an hour will 
be found to be composed of a succession of paroxysms, with 
very brief intermissions, just sufficient to throw a reinforce- 
ment of oxygen into the blood. The light attacks are 
usually short, the severe attacks are usually long, and the 
paroxysms show a strong inclination towards progressive 
severity in regard to intensity, duration and recurrence, and, 
consequently, danger. When the symptoms are of the 
character described as belonging to the severer variety of 
the disease, the paroxysm is almost certain to be followed 
by others in increasingly rapid succession, and the child may 
die almost at once. I had one case in which a fine, healthy 
boy of twenty months had the first and only paroxysm in 
the morning after his bath ; the glottis closed almost with- 
out sound, and the little one died in less than a minute. On 
the other hand, I had two cases in which the little ones had 
but one single paroxysm of great severity, followed by per- 
fect recovery, without any return of the disease. Still, as 
Romberg long ago noticed, it is only in very rare cases that 
recovery or death takes place during the first days of the 
illness. The duration of the affection depends very much 
on the exciting cause. It is rare that a child has one single 
attack ; generally several paroxysms follow each other in 
rapid succession, after which the disease may disappear in 
consequence of the cutting of some teeth, or as the result of 
treatment. The first attack is usually the most severe, 
though when a second paroxysm rapidly follows the first 



SPASM OF THE GLOTTIS. 8 1 

one, almost before the child has recovered from it, the like- 
lihood is that the second will be both long and severe. A 
strong child, previously in good health,- may withstand 
several scores of paroxysms, provided they are not all of the 
more severe type and do not come in too rapid succession. 
Thus Dr. Benedict, of Philadelphia, reports a case, with the 
characteristic spasm of the hands and feet, which lasted for 
four months and a half, and was followed by perfect 
recovery. 

As the child grows older the predisposition to the disease 
declines, and though the paroxysms may still recur, they are 
not nearly so severe, and the danger to life is evidently 
diminished. The explanation is that the laryngeal cartilages 
are firmer, the larynx is larger and especially wider, and the 
entire nervous system is less irritable and impressible. 
When the paroxysms do appear they merely consist in a 
feeling of suffocation and slight difficulty in swallowing, with 
slightly irregular respiration, but no crowing or whistling 
inspiration. Carpo-pedal convulsions have never been ob- 
served in children over five years of age, and they are some- 
what rare from the end of the third to the end of the fifth 
year. 

During the paroxysm it is, a matter of some difficulty even 
to feel the pulse or ausculate the heart, and it is still more 
difficult to make thermometric observations. I. have been 
unable to find any such observations in the libraries to which 
I have access, and can give but a few made by myself under 
exceptional circumstances. Alluding to this point, Vogel 
remarks " temperature of the extremities is much more likely 
to be diminished than increased," and Steffen says that " in 
view of the overloading of the venous system the body, and 
especially the extremities are, as a rule, cool and livid," but 
neither of these skilled observers appears to have used the 
thermometer. In mild cases, then, the temperature varies 
from 98 F. to 98.4 F., that is, a trifle below the temperature 
of the same child when in health, just what one would expect 
in a disease which is not only non-febrile, but, from the 



82 SPASM OF THE GLOTTIS. 

loading of the venous system, positively shows a temperature 
below the healthy standard. In severe cases of spasm of the 
glottis in children not suffering from any febrile disease, the 
thermometer placed in the axilla showed a temperature of 
97. 5° F. shortly after the commencement of the spasm, and 
as it advanced the temperature was lowered till it fell to 
96.5 F. In one instance I succeeded in placing a very 
strong New York thermometer in the hand of a child just 
before the carpo-pedal spasm clenched the fingers, and it 
showed a temperature of 96. 5 ° F. at a time when the axil- 
lary temperature was 97. 5 F. nearly. I was unable to make 
observations on the feet in any of these cases, but I have no 
doubt but that they were cooler than the hands. I made 
careful observations in two children who were suffering from 
the fever of dentition at the time that they were attacked 
with spasm of the glottis, with the following results : The 
thermometer, which had shown a temperature of ioo° F. on 
the previous day and 100.2 F. shortly before the attack, 
showed a temperature of 98. 5 ° F. soon after the commence- 
ment of the attack of spasm of the glottis, and at its height 
the temperature was 97.5° F., showing in both cases an 
average of i° F. above those children who were not suffering 
from teething fever at the time of the paroxysm of spasm of 
the glottis. Observations made by auscultating the larynx 
are still a desideratum, but I have been so intent on making 
thermometric observations that T have only made a very few 
in auscultation, and these are too few and too imperfect for 
publication. 

Notwithstanding all that has been written as to the thymic 
origin of this disease, no characteristic lesion can be 
discovered after death, and the gland is sometimes increased 
in size, at other times it is smaller than usual, or it may be 
almost entirely absorbed. But hypertrophy of the thymus is 
by no means common, and chronic inflammation is quite rare. 
No alteration whatever can be discovered in the laryngeal 
nerves, nor in the laryngeal structure of the muscles; while the 
mucous membrane is slightly reddened only in the rare cases 



SPASM OF THE GLOTTIS. 83 

in which the child suffered from laryngeal catarrh as well as 
spasm of the glottis, so that, as far as the larynx is concerned, 
the purely neurotic nature of the malady is amply confirmed 
by post-mortem examinations. Craniotabes is present in 
many cases, though Steffen says this is by no means the rule, 
and next in frequency you meet with rachitis of the ribs. 
The tracheal and bronchial glands are frequently affected, 
but the lesions are not characteristic. Frequently they are 
more or less swollen and caseated, and this is particularly 
noticeable in the bronchial glands which are sometimes 
found to be mere collections of cheesy tubercles. At times, 
solitary glandular indurations may be found in the intestines, 
and in such cases tuberculosis is apt to be present in the 
lungs. Congestion of the brain and of its membranes have 
often been noticed, but these, though at times predisposing 
causes of the spasm of the glottis, are quite as often effects 
of it, and this is especially the case with the frequently- 
observed oedema of the brain. Steffen remarks that the 
softening of the medulla oblongata has, very occasionally, 
been demonstrated, and at times the brain has been found 
inflamed or even softened. Some observers have noted that 
the pneumo-gastric nerve was hardened, others have seen it 
softened. 

Congestion of the lungs with engorgement of the right side 
of the heart is common, doubtless due to the asphyxia, and 
oedema of the lungs is very often present. Emphysema of 
the lungs is also found as a result of the irregular and 
spasmodic respiration, but, as Dr. J. Lewis Smith points out, 
" slight emphysema occurring in the upper lobes is common 
in infants, even those who have had no serious disease of the 
respiratory organs." The blood is darker than usual, and 
Bednar, and also Rilliet and Barthez found the heart and 
great thoracic vessels filled with black fluid blood, though 
Loeschner asserts that he has always found the thoracic 
organs somewhat anaemic. Finally, more or less congestion 
of the intestinal mucous membrane is usually present, and 
indeed any organ of the body-may be congested as a result 
of spasm of the glottis. 



84 SPASM OF THE GLOTTIS. 

Attention to Dr. Cheyne's pathognomonic sign will tend 
to prevent errors in diagnosis, " a crowing inspiration, with 
purple complexion, not follozved by cough." It has been 
confounded with croup, but in croup the difficulty of 
breathing is permanent or nearly so, and it affects expiration 
as well as inspiration ; but in spasm of the glottis it is inspi- 
ration which is affected. In croup respiration is affected, 
though with difficulty ; but in spasm of the glottis respiration 
is, for a brief time, positively stopped. Croup is accompa- 
nied by severe cough, but this symptom is wholly absent in 
spasm of the glottis. In croup the child is hoarse, but 
hoarseness is not an integral part of spasm of the glottis. 
Croup usually follows exposure to the cold ; spasm of the 
glottis has little dependence on that cause of disease. Lastly, 
croup is usually accompanied by fever, and it has convulsions 
only when about to terminate fatally, while spasm of the 
glottis has no fever and has a most characteristic species of 
convulsion. 

Spasm of the glottis may be confounded with oedema of 
the glottis, but the last mentioned developes gradually, 
whereas spasm of the glottis arises suddenly. The experi- 
enced finger can easily detect the hard and swollen cherry-like 
mucous membrane of the epiglottis, so characteristic of 
oedema, while nothing of the sort is found in spasm of the 
glottis. 

There is a close resemblance between the sounds of 
whooping cough and spasm of the glottis, but in the latter 
disease there is no cough, no expectorations, no vomiting and 
no rattling of mucus in the lungs. Whooping cough almost 
always has a catarrhal stage lasting a week or ten days, 
while spasm of the glottis rarely has any prodromal stage 
whatever. 

" Paralysis of the abductors — a very rare affection in child- 
hood—might be mistaken for spasm of the adductors, and it 
is thus important to carefully distinguish between these two 
conditions. In the paralytic cases there is, as Dr. Marshall 
Hall has pointed out, "a constant bat partial closure" of the 



SPASM OF THE GLOTTIS. 85 

glottis, the vocal cords never being abducted from their 
paralyzed position, but always leaving a small opening 
through which the air can pass. In spasm 'of the adductors, 
on the other hand, there is inconstant but complete closure of 
the glottis ; in other wor.ds, there is considerable movement 
of the cords, which are at one moment widely separated and 
at another so closely approximated that air cannot pass 
through the glottis. The symptom in the one case is 
constant dyspnoea, increased on the slightest exertion, whilst 
in the other it is constant dyspnoea, with complete inter- 
mission between the attacks. This, however, is not an 
absolute law, for on three occasions I have seen slight 
constant stridor in the case of children in whom the other 
symptoms were of spasmodic character, carpo-pedal contrac- 
tions and convulsions (Morell Mackenzie). 

This is always a grave disease, for even in mild cases 
serious symptoms may arise and the prognosis changes at 
once, and Condie remarks that ' a sudden and very severe 
paroxysm may unexpectedly occur at any moment, particu- 
larly during the period of dentition." Dr. John Clarke says 
that the patient rarely recovers, and Dr. Reid collated 289 
cases showing a mortality of 115. Dr. Cheyne and Dr. 
Gooch both state that it proved fatal in one-third of those 
attacked, and only one of the 9 cases seen by Rilliet and 
Barthez recovered, and Herard saved but one out of seven. 
Of Sir Henry Marsh's cases, 5 recovered and 2 died, and' of 
Dr. Hersch's cases, 3 died out of 5 — and one of the fatal 
cases was complicated with whooping cough. Bouchut 
thinks that rather more then than one-half die, while Lorent 
notes 45 deaths of 100 cases occurring in boys and 32 deaths 
in TOO cases occurring in girls. Wunderlich says that one- 
third of all those attacked, and the majority of those visited 
with severe attacks die, and Steiner, a physician of vast ex- 
perience, is sure that the great majority die. 

On the other hand Steffen says that, if we include the 
lightest cases, which we certainly should, the prognosis is, on 
the whole, favorable, and Salathe lost but 2 cases out of 24. 



86 SPASM OF THE GLOTTIS. 

Morell Mackenzie says that spasm of, the glottis " rarely 
proves fatal," which is not by any means the general expe- 
rience. Notwithstanding all these opinions, almost all of 
them unfavorable, the writer's 28 cases all recovered save 
two, one of which was the fondroy 'ante case referred to, and 
the same result may almost always be expected from an 
enlightened homoeopathic treatment. 

Spasm of the glottis is more dangerous to young children 
than to older ones, for in the latter the laryngeal cartilages 
are harder, the larynx is wider, and the nervous system is 
less impressible. Children at the breast do better than 
those who have been weaned. The prognosis is more favor- 
able in girls than in boys. Emaciated children have less 
chance of doing well than well-nourished children. The 
lower the temperature during the attack the greater the 
danger. The longer the interval between the spasms the 
better the chance of recovery. General convulsions or 
carpo-pedal contractions add greatly to the gloom of the 
prognosis. The danger is greater when the malady results 
from intracranial disease than when it depends on dentition 
or on some stomach attack. Diarrhoea, continued vomiting, 
or anything which lowers the powers of life, vitiate the prog- 
nosis. Ryland and Ley both refer to bronchitis as an oc- 
casional exciting cause of the disease, while Steffen asserts 
that " acute pneumonia usually effects a material abatement 
and even complete disappearance of the laryngeal cramp." 
Children far gone in rachitis, especially if craniotabes is 
present, are usually considered less likely to recover than 
those of healthy constitution, yet Steffen maintains that 
" the most favorable cases are those in which it is developed 
as the result of rachitis." Scrofula, which finds its expres- 
sion in swelling and caseation of the tracheal and bronchial 
glands, renders the prognosis more doubtful. Children who 
have had one attack should never be considered safe till the 
completion of the first dentition. Long-continued and severe 
spasms, with cyanotic face and symptoms of suffocation, 
often presage an unfavorable issue. If remedies are prompt- 
ly and faithfully used by a physician who has carefully stud- 



SPASM OF THE GLOTTIS. 87 

ied the disease the chances of recovery are much better than 
if remedies are carelessly used by a practitioner who knows 
little or nothing of the disease. 

Death takes place in three distinct modes. The first is 
apncea, when the child is choked during the paroxysm ; first 
respiration is suspended, then after a few hurried beats the 
pulse ceases, and the lungs and heart are found to be flooded 
with dark blood. Or death may take place when the current 
of blood is prevented from passing from the brain to the 
heart and lungs, and if this state — really congestion — is not 
promptly relieved, effusion takes place and the child dies 
comatose. Lastly, death may take place from exhaustion ; 
the strength is reduced by a constant succession of severe 
paroxysms, diarrhoea sets in, and death closes the scene. 

Sambucus is the classic remedy of our school for spasm of 
the glottis, recommended before all others, though it cannot 
be looked upon as being the leading specific, and there is a 
growing inclination to question its efficacy. Dr. Drysdale 
has not seen any good effects from it, while Dr. W. S. Searle, 
of Brooklyn, after stating that Sambucus was the remedy 
selected by Hahnemann for the disease, goes on to say that 
"its signal failure to cure the large majority of cases has led 
some to question whether the usual sagacity of the master 
did not desert him on this occasion ;" adding further, " the 
fact, however, does not prove that the remedy is not home- 
cepathic to some modalities of the disease, and the trouble 
lies in our failure to discover these modalities ; not in 
Hahnemann nor in the remedy." Baehr thinks that the 
striking case reported by Hartmann does not represent a 
high degree of spasm of the glottis, while Farrington thinks 
that " its symptoms do not seem to point distinctively to a 
spasm of the glottis." Ruddock recommends during the 
attack a very prompt administration of Aconite, alternated 
with Sambucus, for " fear of suffocation and dry cough," but 
as the indications for Aconite are wholly distinct from those 
for Sambucus, it is decidedly best to give the remedy indi- 
cated, singly a?id alone. Hughes, one of our best authori- 
ties, says that " Sambucus is in high esteem." 



88 SPASM OF THE GLOTTIS. 

The attack takes place suddenly ; the patient awakes from 
a kind of lethargy with the eyes and the mouth open ; he 
raises himself in bed with great anxiety and dyspnoea, the 
respiration is oppressed, with wheezing in the chest, the 
head and hands are puffed and bloated, with dry heat over 
the whole body, no thirst, small, irregular and intermittent 
pulse. The patient tosses about anxiously and is unable to 
sleep. There is no cough, and the attack principally occurs 
from midnight to 4 A. M. After the paroxysm, the child 
perspires profusely, and Sambucus is said to be the leading 
remedy when the disease originates in suppressed perspira- 
tion. Dunham points out that while Chlorine has difficulty 
in expiring, none in inspiration, Sambucus has the reverse. 
Searle gives the following determining indications : " Burn- 
ing, red, hot face, hot body, with cold hands and feet during 
sleep. On awaking, the face breaks out into a profuse 
perspiration, which extends over the body, and continues, 
more or less, during the waking hours ; then, on going to 
sleep again, the dry heat returns ; " adding, "should you ever 
meet with a case presenting these peculiarites, you may be 
sure Sambucus will cure it, and nearly as sure that it 
will fail if these symptoms are absent." During the last few 
years I have only met with two cases in which Sambucus 
was indicated, but the results were striking and prompt, and 
I was greatly helped by Searle's laconic but invaluable indi- 
cations. Sambucus has usually been given in drop doses of 
the 1st, 2d or 3d dilutions, though Hartmann thinks that a 
" higher attenuation may perhaps do better and prevent a 
recurrence." 

Moschus is recommended by several of the standard 
writers, though Hempel says that it acts in accordance with 
the principle of Contraria, while Hartmann thinks that it is 
very far from being a specific remedy. " Moschus is vari- 
ously recommended for this disease, but we cannot see its 
homceopathicity to it. We are not acquainted with any 
decided cures that Moschus has effected in this disease, 
Hartmann's statement to the contrary notwithstanding." 



SPASM OF THE GLOTTIS. 89 

(Bsehr.) Drysdale brackets Moschus with Sambucus, but 
he has never seen any good effect from either. Searle states 
that it " is said to have cured laryngismus, probably hys- 
teric in character," while Hughes affirms that his own ex- 
perience has led him to believe smelling at Moschus to be the 
best means of relief during the paroxysm. " Moschus causes 
a spasm of the throat, larynx and lungs — sudden sensation, 
as if the larynx closed on the breath, as from inhaling sul- 
phur-vapor. It is more applicable to hysterical cases, and 
possibly to spasm of the glottis during the course of dis- 
eases which exhibit impending paralysis of the pneumo- 
gastric nerve." (Farrington.) Dr. Pemerl, of Munich, 
writes: " If neither the chest nor the abdomen is affected, 
and we have only to battle against a reflex irritation of the 
nervous trigeminus, I prefer the exhibition of Moschus 1 
or 2 in quickly succeeding doses, and usually I could be 
satisfied with the results ; but Moschus is never of any use 
whatever when abdominal or thoracic affections underlie the 
spasmus glottidis." Kafka reports a case of laryngismus 
spasmodicus, in a girl five years of age, of light complexion, 
with sudden attacks of crowing and protracted inspiration. 
The spasm of the glottis was improved by Veratrum, but 
cured very quickly with Moschus 12, one drop every two 
hours. Laurie recommends one globule of the 3d dilution 
in a teaspoonful of water, repeated at intervals of half an 
hour until three doses have been given ; and subsequently 
at intervals of two hours, until decided amelioration or 
change. For olfaction, as advised by Hughes, the 1st deci- 
mal trituration would be preferable. 

Aconite is not even mentioned by either Hughes or Baehr, 
and Searle omits it from the list of remedies — Chlorine, 
Mephitis, Sambucus, Moschus and Lachesis — of which he 
says, "besides these five, I am unable to find any remedies 
that have cured, or are likely to cure, a case of true spasmus 
glottidis." On the other hand, according to Prof. Walter 
Williamson, Aconite is " specific," while Hempel says " yve 
have cured more than one spasm of the glottis radically with 



90 SPASM OF THE GLOTTIS. 

nothing but the first attenuation of Aconite root" and again 
he says, "we affirm that we have effected cures of this 
disease with Aconite alone, without using any other medicine. 
We mix a drop or two of the first decimal attenuation of the 
root in two tablespoonfuls of water, and give ten or fifteen 
drops of this mixture every two or three minutes, until the 
patient is decidedly easier. If no positive relief is obtained 
after giving a few doses, we substitute a drop of the tincture 
in the same manner as before." Jahr, under the caption of 
" Spasm of the Glottis, Asthma Thymicum, Kopp," writes, 
"After I had cured my daughter, a child of five years, in 
1849, °f tn i s disease, which set in one morning with all the 
frightful symptoms of true croup, and I expected every 
moment to see her perish of asphyxia, in less than ten 
minutes, by means of a single dose of Aeon., 30, three 
globules; I have commenced the treatment of this spasm in 
every subsequent case with Aeon., thereby unfortunately 
creating a belief that croup can be w r iped out, as it were, by 
a stroke of magic. Not every case of spasm of the glottis 
can be cured so easily with Aeon, alone, although this 
remedy never fails, if no complications are present, to afford 
speedy help." I side with my lamented friend, Hempel, for 
I have seen the happiest results from Aconite, given as he 
directs, in spasm of the glottis. Aconite is indicated when 
a suffocating cough comes on suddenly at night with hoarse 
voice and shrill outcry; the respiration is short and anxious; 
the skin is dry and hot ; the pulse is full, hard and greatly 
accelerated. Good results have been seen from all doses, 
from the Hempelite mother-tincture to the Hahnemannian 
30th dilution, but in acute cases I have never given it higher 
than the 1st decimal dilution, while in protracted cases I 
have used from the 6th decimal trituration to the 12th cen- 
tesimal dilution. 

In 1869, writing on this disease, I spoke as follows on the 
use of Sanguinaria : " My own experience leads me to look 
upon Sanguinaria as being the Imperial Guard of all the 
remedies for spasm of the glottis. After using this remedy 



SPASM OF THE GLOTTIS. 9 1 

successfully in the various forms of croup, I was induced to 
give it in two apparently desperate cases of spasm of the 
glottis after the unsuccessful use of Aconite, Sambucus and 
other apparently well-indicated remedies. I was gratified to 
find its administration followed by rapid and durable cures, 
and I now look upon it as being the first remedy. I give it 
in the form of an acetous syrup." Now, after an enlarged 
experience, I feel still more confidence in this little-used but 
invaluable remedy. 

Brilliant cures have been effected with Arsenicum album, 
especially when the disease assumes the chronic form, Drys- 
dale mentions it as one of the medicines which he has found, 
on the whole, most useful in this disease, and Bsehr thinks 
that it deserves our attention if, as is often the case, the 
disease attacks feeble children with marked symptoms of 
cerebral anaemia. The attack is preceded for several days 
by catarrhal symptoms ; the little patient goes to sleep 
quietly, and the spasm comes on suddenly in the night, 
threatening suffocation ; the respiration is short and hissing. 
There is great anguish with copious perspiration ; prostration 
of strength with aggravation of all the symptoms between 
midnight and daylight. The child breathes freely between 
the attacks, but is languid and restless. " In my opinion 
Arsenicum is the true specific for this disease. Not to 
mention the peculiar sense of suffocation or constriction in 
the larynx, with stoppage of breath, what drug has more 
than Arsenic the peculiarity of producing such a paroxysm 
at night, waking the child suddenly? or after trifling causes 
such as crying, laughing, getting choked by a little food or 
drink, etc.? What drug has the typical recurrence of the 
first paroxysms at decreasing intervals? the apparently 
insignificant prodromi of such a dangerous disease? the 
sudden disappearance of the spasm by violently shaking the 
child ?" (Hartmann.) I have had better results from the 
30th dilution than from the lower preparations, and I never 
saw any good results from Arsenicum save in cases such as 
Bsehr describes. 



92 SPASM OF THE GLOTTIS. 

Belladonna is the principal remedy when the brain is 
seriously involved, when the head is hot and the face 
alternately flushed and pale, and all the symptoms point to 
cerebral congestion. It is of great service when the child's 
head is large and when the carpo-pedal spasms are present. 
Hughes says it must be given where there is arterial excite- 
ment and cerebral congestion, and Jahr recommends it 
especially in the case of scrofulous children. Baehr observes 
that " Belladonna is only adapted to spasm of the glottis 
when occurring as a secondary symptom in other diseases," 
but the force of the objection is broken by the fact that 
spasm of the glottis is very often indeed " a secondary 
symptom in other diseases," but not the less dangerous on 
that account. The little one is over-susceptible to impres- 
sions, and this is aggravated by bright light, noises, the 
slightest contradiction, by dentition, or by the presence of 
irritating or indigestible substances in the intestinal canal. 
The respiration during sleep is irregular or intermittent, and 
on falling asleep the child wakes and starts as if frightened. 
The sleep is restless, tossing about the bed, quarrelling in 
sleep, talking or crying out. The larynx, which had been 
sensitive to pressure, suddenly feels constricted with violent 
struggles for breath, and the smallest quantity of fluid drank 
excites a spasm. The brain is excited, the face red, the eyes 
injected with squinting or dilated pupils, the teeth are 
clenched, and fearful convulsions of the flexor muscles set 
in ; frequently opisthotonic convulsions. " It seems to be 
indicated by the characteristic spasm in the larynx, and may 
be given to children of every variety of constitution, plethoric 
or lymphatic, scrofulous, rickety, etc., and more particularly 
when bad management has induced collateral complications 
or cerebral affections." (Hartmann.) Belladonna has been 
used in all potencies in this disease. Thus Dr. E. Clarke, of 
Portland, reports a case in the North American Journal of 
Homoeopathy, vol. XX, in which Belladonna in the 200th and 
400th dilutions rendered excellent service, and on the other 
hand, Dr. J. N. Tilden, of Peekskill, N. Y., reports the 



SPASM OF THE GLOTTIS. 93 

following cases, which are really model cures, in the Homoeo- 
pathic Times for 1878: 

" Case i. — A delicate child, set. 8 months; artificially fed, 
digestion in perfect condition. His paroxysms were always 
precipitated by crying from anger. They were characterized 
by a sudden and complete cessation of respiration, as if the 
rima glottidis were completely closed to the entrance of air, 
and accompanied by alarming lividity of the face, lasting 
for from ten to twenty seconds, when the first inspiration 
would be accompanied by a shrill crowing sound almost 
identical with the characteristic inspiration of whooping 
cough. After this prolonged inspiration the breathing would 
be irregular and sighing, and the discolored features would 
be followed by pallor, accompanied with great prostration, 
and cold perspiration lasting for half an hour or more. These 
alarming attacks occurred at irregular intervals, sometimes 
daily, often at longer periods. Strict attention to regimen, 
abundant out-door recreation was directed, and Belladonna 
1st dec. given internally every two hours while awake. A 
marked diminution in the severity of the symptoms was at 
once noted, and after a few days' treatment the attacks 
ceased entirely. 

"Case 2. — Child; set. 9 months, suffering from teething and 
indigestion, had paroxysms every time he waked from sleep. 
In this instance they consisted of ineffectual spasmodic 
efforts at inspiration, attended with the same shrill, crowing 
sound mentioned as occurring in the other case. This 
patient did not have so much congestion, nor were the par- 
oxysms followed with so great prostration as in the previous 
patient ; but during the attacks, which lasted one or two 
minutes, it seemed as if the little fellow must surely suffocate. 

" The difference in the symptoms noted in the two cases 
was probably owing to the fact that in the first case the 
rima glottidis was entirely closed, and in the second, though 
rigid and unyielding, it was open sufficiently to allow the 
entrance of a limited amount of air. 

" The treatment was the same in this case as in the preced- 



94 SPASM OF THE GLOTTIS. 

ing one — Belladonna — and the result was equally prompt 
and satisfactory. The paroxysms were at once ameliorated, 
and after three or four days there were no more symptoms 
of them." 

My own experience with Belladonna in this disease 
decidedly.leads me to favor the measure dose, though I have 
never descended to the 1st decimal dilution, having seen 
excellent results from the 3d to the 5th decimal. In the 
intervals of the paroxysms I have given the 12th and 30th 
centesimal dilutions with fine results. 

Ruoff and Jahr speak favorably of Ipec. Searle does 
'not mention it, and Pemerl, of Munich, recommends it 
''when we find sabilant rouchet with dry, titillating, frequent 
and tormenting cough — a morbid state little likely to be 
found in pure spasm of the glottis— and these indications 
can only hold good when a laryngeal catarrh precedes or 
accompanies the disease. " Ipecacuanha has been mentioned 
as a remedy ; indeed the symptoms justify this recommen- 
dation. We should not, however, overlook the fact that 
asthmatic difficulties do not really occur in this disease. 
Relief is easily afforded if a remedy is given at the outset, 
but it does not last, and we cannot recommend a remedy as 
a specific, unless it controls the whole disease. We admit, 
however, that Ipecacuanha may have an excellent effect, for 
the time at least, in a catarrh accompanying spasm of- the 
glottis," (Baehr.) 

I have given Ipecacuanha with success when the spasm o*f 
the glottis was excited by the reflex influence of indigestible 
food, the attack being preceded by nausea and vomiting and 
even by purging ; also when the disease was caused by taking 
cold, and thus was associated with a catarrh of the larynx. 
The symptoms are rattling in the trachea and lungs from 
accumulated mucus, with spasmodic contraction in the 
laryngeal region, with threatening suffocation, anxious and 
short or sighing respiration, together with purple color of 
the face and cramps and rigidity of the body. 

" As regards laryngismus stridulus, having had several 



SPASM OF THE GLOTTIS. 95 

cases of it, we can speak from experience of the efficacy of 
Sambucus and Ipecacuanha in curing it. We once had a 
case of laryngismus in which the whooping-cough super- 
vened. The suffocative spasms were of the most painful 
description. When a fit of coughing came on, and the child 
had at the same time an outburst of passion (the usual 
exciting cause of the attacks of laryngismus in this case), the 
child would scarcely have begun to cough when he lost all 
power of respiring altogether. He grew literally black in 
the face ; his head fell backwards, and there he lay for some 
seconds apparently beyond all recovery. He revived on 
putting his head out of the window, or dashing cold. water 
in his face. Ipecacuanha effected a cure." {British Journal 
of Homoeopathy, XII, p. 457.) 

As to the dose, Laurie advises to dissolve 3 globules of 
the 3d dilution in six teaspoonfuls of water; give a tea- 
spoonful every quarter of an hour, until three doses have 
been given, after which the intervals must be lengthened, or 
the medici-ne suspended, if decided improvement or a cessa- 
tion of the symptoms of impending suffocation ensues. I 
have always used the 3d, 4th, or 5th decimal triturations in 
the manner recommended by Laurie. 

Gelsemium sempervirens was introduced to the profession 
by Dr. E. M. Hale, of Chicago, who considers that " if not 
a curative remedy, properly, it will be a valuable palliative, 
used in drop doses of the first dilution, or mother tincture, 
frequently repeated ; it must procure relief in a majority of 
cases, while during the intermediate time it should be alter- 
nated with Belladonna, Hyosciamus, Arsenicum orMoschus." 
In a recent edition of his invaluable work he writes as follows : 
" The primary effect of Gelsemium is to paralyze the mus- 
cles of the tongue, glottis and the whole apparatus concerned 
in deglutition and vocal efforts, but this paralysis is not 
attended by the numbness and tingling caused by Aconite ; 
the secondary effects of the drug result in spasmodic and 
tetanic conditions of the same muscular structures. 

You will be able to cure as I have cured, some sudden and 



g6 SPASM OF THE GLOTTIS. 

alarming paralytic affections of the throat with the high dilu- 
tions ; while in spasm of the glottis and spasmodic croup you 
will be successful with more material doses." Ruddock re- 
marks that it is an excellent reserve medicine for an occasional 
acute attack which does not yield promptly and fully to Aco- 
nite, and it is one of the very few remedies endorsed by Raue. 
The indications are long inspiration with croupy sound, 
expiration sudden and forcible. Sudden and severe attacks 
of dyspnoea, with crowing noise, profuse perspiration and 
darkly flushed face. 

In the fifth volume of the Homoeopathic World, Dr. Ad- 
rien Stokes of Southport, England, relates two cases of 
spasm of the glottis cured by Gelsemium, of the first of 
which the following is a summary : The patient, twenty- 
one years of age, had had diphtheria, and three months after- 
wards, when first seen by the doctor, appeared to suffer from 
laryngeal catarrh. There was some tenderness of the 
trachea on touch, and an increasing difficulty of inspiration 
towards evening. Mercurius was given, but at midnight the 
doctor was summoned, and found the patient in »bed, 
propped up with pillows, her hands pressed upon the bed 
beside her, the face ashy, the lips livid, and the countenance 
wearing an anxious expression. Respiration was very diffi- 
cult, and the pulse thready and feeble. The finger-nails were 
livid, and the hands stiff. The larynx w T as very tender, and 
became increasingly so. Deglutition was difficult, and 
became more so as time went on. The doctor saw that 
he had before him a very formidable case of trachetis, with 
intense spasm of the glottis ; and as the patient had only 
just recovered from a serious illness, he was inclined to fear 
this one would turn out to be rather unmanageable. Aconite 
and Belladonna were given in succession, but equally without 
benefit ; the distress increasing with an increasing dyspnoea, 
the lips were blue and the hands also, the arms being rigid 
up to the elbow. In this emergency Dr. Harvey was called 
in, when Bromine was given by inhalation and Aconite every 
fifteen minutes, but the patient got rapidly worse, and the 



SPASM OF THE GLOTTIS. 97 

medical attendants were in fear of seeing her perish of 
asphyxia before their eyes ; the power of deglutition had 
almost ceased — hands and feet were cold. In this desperate 
strait, Stokes happily thought of Gelsemium, of which a 
portion of a drop of the mother-tincture was at once given. 
The effect was something akin to the marvellous. " Scarcely 
had the fluid passed over the tongue when we saw the 
inspirations lengthen,, and felt the hands relax from their 
rigidity. The countenance began at once to brighten, the 
hands soon regained a more natural appearance, and the 
whole bearing of the patient was easier and happier. In a 
quarter of an hour we gave the remains of the dose, and so 
rapid was the improvement that in another quarter of an 
hour we were able to go home to bed. I had been with her 
four hours, but had I thought earlier of using Gelsemium I 
need not have had an anxious and broken night." A rapid 
cure followed, though the larynx continued intensely tender 
and deglutition difficult for a week. 

The second case was a young lady thirteen years of age, 
prone to laryngeal disease. "I went at once and "saw this 
child in a state of intense distress. The old nurse was try- 
ing to hold her on her lap, but she was dashing herself about 
in a frenzy of fright and agony. The face was purple, the 
eyes protruding, the larynx was spasmodically jerked up and 
down, and suffocation seemed imminent. I thought at once 
of Gelsemium and how it had served me before. So mixing 
two drops of mother tincture in four teaspoonfuls of water, 
I gave her one teaspoonful of the mixture, and bade the 
mother watch the effect. In five minutes there seemed to 
be a slight improvement, inasmuch as the movements were 
less frantic and violent. A second dose was given, and in 
five minutes more a visible change had come on. The 
patient could now take breath more easily, sat still on the 
nurse's knee, and the acute and strident sound of the inspira- 
tion had given way. The mother watched and wondered ; but 
we gave another dose at the expiry of five minutes after the 
last, and by that time all distress had passed away. I 



98 SPASM OF THE GLOTTIS. 

remained while the patient was being put to bed, and was in 
the house half an hour in all. The larynx remained very- 
tender for a week, but I continued to treat the case with 
Gelseminum and Mercurius, and kept her in one room all 
the time." 

Iodium is not merely homoeopathic to the acute attack, 
but it is also one of the deeper-acting remedies which must 
be given if the cause is to be reached. We owe this remedy 
dy to Baehr, who thus introduces it to the notice of our 
school : " Iodium is doubtless a very excellent simile, and 
is likewise adapted to all three above-named causal morbid 
conditions. (These conditions are rachitis, a deficient invo- 
lution or hypertrophy of the thymus gland, and swelling of 
the bronchial glands.) With this reme,dy alone, given every 
other day at the fourth or sixth attenuation for four to eight 
weeks ; we have cured five undoubted cases of spasm of the 
glottis, which evidenced their malignant nature by the fact 
that every subsequent attack was more violent than the pre- 
ceding one. The patients were children not yet a year old, 
but only one of them showed an enlargement of the thymus 
gland. Supported by such striking curative results, we can- 
not be accused of hazardous speculation if we prefer this 
remedy to all others, as long as the general organism has 
not become too much reduced." The following are the 
indications usually given for this remedy, though it must be 
confessed that they are somewhat vague : Rachitic children ; 
swelling of the bronchial glands ; tightness and constriction 
about the larynx ; soreness, hoarse voice, etc.; enlarged glands 
may even cause paralysis of the laryngeal, tracheal and bron- 
chial nerves. Dunham gives the following indications : en- 
largement and induration of the glands, cervical and mesen- 
teric ; absence of appetite; utter indifference to food; 
scanty, high-colored urine ; clayey evacuations ; emaciation ; 
yellow skin : action of the heart feeble, and much increased 
by motion. Guided by these indications, Dunham reports 
the following striking case : 

." The case for which I recently prescribed Iodine was that 



SPASM OF THE GLOTTIS. 99 

of an infant of ten months, whose mother states that, early 
in life, the child had marasmus, and was very low. Recov- 
ering from this, under homoeopathic treatment, she had a 
wheezing or rattling in the chest, which gradually increased 
for two months, until she could be heard breathing at a 
great distance. She coughed for a week or two, then the 
cough ceased. About August 1st she began to have spasms 
of breathlessness, occurring usually at night, when asleep, 
and during the day while asleep, and seeming as if they 
would take her life. I could not distinguish a special indi- 
cation for any remedy in any peculiarity of these spasms, 
and otherwise the child seemed perfectly well. I therefore 
adopted a plan which has often helped me in blind cases. 
I went back on the line of development of the child's sym- 
toms, until I found symptoms which furnished an indication 
and then prescribed as though these symptoms were now 
present. Adopting this plan, it may be remembered I, 
years ago, prescribed for a deaf young man of seventeen 
years, Mezereum, which corresponded to the milk crust, the 
suppression of which, twelve years before, had been immedi- 
ately followed by the deafness. I prescribed just as though 
the milk crust was actually present, and the deafness was 
speedily and permanently cured. Acting on this plan, I 
recalled the marasmus which the child had had, and the 
symptoms of which, as described to me, indicated Iodium. 
This remedy was certainly not contra-indicated by the affec- 
tion of the glottis, which was, I think, a partial paralysis and 
not spasm. The attacks of dyspnoea gradually ceased, and 
within ten days had disappeared. The potency used was 
the two hundredth. 

Dr. Dunham says that the breathing furnished no particular 
indication for Iodine more than for Spongia or Sambucus, so 
that we must fall back on the general indications already 
given. Personally, I have had no experience with this 
remedy. * 

Chlorine is, according to Searle, the most prominent of the 
remedies for spasm of the glottis, and he thinks that a large 



IOO SPASM OF THE GLOTTIS. 

majority of instances of simple idiopathic spasmus glottidis 
may be expected to yield to it. Still, he candidly admits 
that the symptoms produced by it are those which occur in 
every case of spasm of the glottis, to a greater or less extent, 
adding that "the characteristic and distinctive symptoms of 
the drug have never been evolved." The attacks come on 
suddenly and without warning, the child takes a long inspira- 
tion with a slight crowing noise, but he cannot make the 
expiration ; inspiration, when again made, was found easy 
enough, but attended by a slight crowing sound, expiration 
again impossible. The face was livid, with blueness of the 
mouth. The lungs are fearfully distended from frequent 
inspiration without any corresponding exit of air, and this 
finally results in more or less complete asphyxia, with or 
without convulsions, during which the spasm relaxes and free 
respiration takes place. The attacks come on after excite- 
ment, during sleep, and they are most common from midnight 
till seven A. M. 

Dr. Dunham, who introduced Chlorine to our notice, gives 
us the following instructive cases : 

"June 24th. A female infant, seven months old, well 
developed and large, the fourth child of healthy parents, was 
brought to me with the following history: Having been 
previously in perfect health, she was seized three weeks ago 
with a spasmodic affection of the respiratory organs. Sud- 
denly, and without any warning, she would make a long 
inspiration, with a slight crowing noise ; an attempt to exhale 
would be made, but without success ; another crowing 
inspiration followed by a forcible but ineffectual effort to 
exhale, and this would be repeated until the child became 
blue around the mouth, and sank into partial unconscious- 
ness, when free respiration would take place, and the child 
would generally sink into a deep sleep. Frequently towards 
the close of an attack, convulsive movements of the extrem- 
ities would be noticed, and once general spasm occurred. At 
first these attacks came on only after some excitement, or 
on the child being startled. They frequently occurred during 



SPASM OF THE GLOTTIS. tOI 

sleep, arousing the child suddenly, and they were most 
frequent from midnight to 7 A. M. Within the week before 
I. saw her, they had become very frequent' — as many as 30 
to 40 occurring during the 24 hours. The child had begun 
to emaciate rapidly, had lost appetite, strength and playful- 
ness, the face was pale and bloated, and the eyes had a dull 
and glassy expression. The child had been under most 
skillful homoeopathic treatment since the commencement of 
the attacks, and as she failed to improve, change of air was 
recommended, and she was brought to Newburgh. The 
climate failing to benefit her, the child was placed under my 
care. The case seemed all the more serious from the fact 
that, last year, the parents had lost an older child, a boy, 
with the same affection. In the fourth week of the disease, 
of which the course had been in every respect similar to that 
of the infant above narrated, convulsions supervened, and 
the child died at the end of the sixth week. This child was 
under enlightened allopathic care. It may be interesting to 
note that the autopsy revealed no malformation, and no 
organic lesion ; simply emaciation and atrophy. 

" On careful examination of my little patient, I could 
discover nothing abnormal in the condition of the heart or 
lungs, and no sign of disease that was not fairly attributed 
to the frequent recurrence of these spasms, with the venous 
congestion consequent upon them, It was evidently a case 
of Spasmus Glottidis (asthma thymicum, asthma millari, 
asthma laryngeum infantum, laryngismus stridulus), and had 
advanced almost to the second or convulsive stage in which 
the prognosis is decidedly unfavorable. 

" The remedy which is recommended before all others for 
this disease, in our hand-books and repertories, is Sambucus. 
The symptoms on which this recommendation is based are 
the following: * Slumber with half-open eyes and mouth ; on 
awakening from it he could not draw a breath, and was com- 
pelled to sit up, whereupon respiration was very hurried with 
wheezing in the chest, as if he should suffocate ; he lashed 
about with his hands ; the head and face were bloated and 



102 SPASM OF THE GLOTTIS. 

bluish ; he was hot without thirst ; weeping at the approach 
of a paroxysm ; all this without cough, and especially at 
night from twelve to four o'clock.' On comparing this 
picture with the case under consideration, we find corre- 
spondences in the general characters of the affection. The 
spasmodic embarrassment of respiration, the absence of fever 
and of cough, the occurrence of the paroxysms suddenly, 
chiefly at night, and on awaking show a general appropriate- 
ness of Sambucus to spasm of the larynx and bronchial 
tubes. But we seek in vain for the unequal disturbance of 
the inspiratory and the expiratory act, which are the itidi- 
vidual and therefore the characteristic peculiarity of the case 
under consideration. And failing to find this, we should, as 
a matter of course, expect that Sambucus would fail to cure, 
or in any way to affect the case. And this had been the 
fact. So, too, of Lachesis and several other remedies which, 
as well as Sambucus, had already been tried before the case 
came under my care. In this very peculiarity, which was 
characteristic of the case, the similarity of Chlorine was most 
striking. And it was with the utmost confidence of a happy 
result that I determined, after a careful examination of the 
case, to administer Chlorine. I accordingly prepared a 
saturated solution of Chlorine gas in water of 6o° Fahrenheit, 
and made from this the first centesimal dilution in which the 
odor of the Chlorine could be faintly perceived. 

" Of this, I ordered twenty drops to be dissolved in four 
tablespoonfuls of water, and a teaspoonful to be given to 
the child every three hours (a porcelain spoon was used). 
I also directed a few drops to be placed in the child's mouth 
at the beginning of each paroxysm if this should be possible. 

" The first dose was given at four P. M., June 24th. During 
the preceding twenty-four hours the child had had forty 
paroxysms. During the succeeding twenty-four hours, there 
occurred but four paroxysms ; only one of which began with 
any severity, and this one was instantly arrested midway by 
a few drops of the solution placed upon the child's tongue. 
During the night of the *26th, not a single paroxysm. 



SPASM OF THE GLOTTIS. 103 

Improvement in the general condition of the patient now 
became apparent, appetite and playfulness returned, the 
bloated aspect of the face and the dulness of the eye disap- 
peared. On the 27th, the paroxysms increased in number 
and severity. On examining the solution I found that it had 
changed in, character, and no longer contained Chlorine. A 
fresh solution was prepared, and henceforward it was prepared 
fresh every second day. From this time, July 1st, the remedy 
was continued ; a dose every four hours — when the spasms 
having wholly ceased, and the child appearing well, it was 
finally discontinued. On the 2d of July a slight spasm 
occurred, and the child appeared feverish and excited — with 
greenish diarrhoea. I found a lower incisor pressing strongly 
upon the gum, which was hot and swollen, and which I 
forthwith lanced. In two hours the child had lost every 
trace of illness. Since that date she has continued in good 
health, with the exception of some trifling disorder attendant 
upon dentition. There has been no sign of a recurrence of 
the spasm of the glottis." 

" Last month I was called to a child two years and a half 
old, which had just been brought home from the country, 
and was supposed to be at the point of death. Five weeks 
before, it had sickened with scarlatina, which, according to 
the physicians in attendance, had become complicated by 
diphtheria, and this by inflammation of the right lung and 
deposit therein. An abscess had formed and discharged ex- 
ternally on the neck, leaving an ulcer about two ieches long 
and one and a half broad, which exposed the cervical muscles 
and showed no disposition to heal ; copious and very offen- 
sive discharge from both ears ; the throat seemed to be full 
of a thick, yellow matter, very offensive, which the child 
would occasionally eject, but seemed, for the most, to be 
unable to move either up or down. Any attempt to exam- 
ine the throat, or, on the part of the child, to open the 
mouth to take food or drink, or any attempt to cough, pro- 
duced a fearful spasm of the glottis, which seemed to admit 
the air well enough, but to prevent its exit, and which lasted 



104 SPASM OF THE GLOTTIS. 

until the child became livid and sank exhausted, and this 
constituted, in the opinion of my predecessors, the insupera- 
ble obstacle to the child's recovery. The spasm prevented 
its tasting food. No food had been taken for a week, *and 
very little during the entire illness. The child was now 
very feeble and greatly emaciated. Its death had been 
hourly looked for by the doctors. 

" I prepared immediately some Chlorine water, diluted, 
until the gas was just perceptible, and gave it to the child. 
He took a mouthful and began to choke with the spasm ; I 
immediately placed near his face a handkerchief wet with 
strong Chlorine water, so that he might inhale the gas. The 
spasm ceased instantly and he swallowed. I left orders for 
a similar procedure whenever, from any cause, whether 
coughing or swallowing, the spasm should be induced. It 
never failed to arrest the spasmodic action and enable the 
child to swallow, or to eject the matter from the throat. A 
number of days elapsed before the child could make an ar- 
ticulate sound, or any sound. The doctors had thought the 
diphtheria had induced paralysis of some of the pharyngeal 
muscles, and perhaps others, and hence the spasm in associ- 
ate and neighboring muscles ; and it may be so. They 
regarded the spasm as an insuperable barrier to recovery. 
It was evident to every attendant that the Chlorine relaxed 
the spasm and enabled the child to swallow. His subse- 
quent improvement was uniform and rapid under Carbo 
vegetabilis 200." 

Cuprum is, according to Bsehr, particularly appropriate if, 
during the local spasm, general convulsions have supervened 
and the child has become very much prostrated, and Hughes 
remarks that whereas Belladonna should be given where 
there is arterial excitement and cerebral congestion, "Cuprum 
should be given where these symptoms are absent " — that is, 
when the morbid state is a pure neurosis. Farrington thinks 
Cuprum well adapted to cases which have advanced to the 
convulsive stage, and Jahr advises that if the spasm of the 
glottis sets in in company with other spasmodic symptoms 



SPASM OF THE GLOTTIS. 105 

to give " above all Cuprum," and I have certainly never seen 
any good effects from this remedy save under these circum- 
stances. Duncan, too, tersely says" Cuprum is the remedy." 
Cuprum is indicated by short, panting, whistling breathing, 
with gurgling down the oesophagus, and on attempting to 
take a deep breath there is a dyspnoea, with stridulous 
inspiration. This local, morbid state is accompanied by 
general convulsions, the body being stiff with spasmodic 
twitching and clenched thumbs. The face and lips are both 
alike blue, and the face is sometimes covered with cold 
sweat. The paroxysms come on suddenly and cease sud- 
denly, after fright of mother or child. Searle calls attention 
to cold perspiration at night as being a kind of key note, 
and Baehr says that among the symptoms indicating the 
remedy one is particularly noticeable — vomiting after the 
attack. 

" A delicate girl, nine months old, had for several days 
suffered with a cough, spasmodic and more violent during 
the night, peevishness, no fever, quick, difficult breathing, 
drawing in of the muscles of the right and left hypochon- 
driac regions during inspiration, percussion normal, rattling 
of mucus far down, little appetite, tongue with whitish coat- 
ing, daily, one or two thin, sometimes watery, sometimes 
greenish stools. Ipec. 9 every two hours. While asleep the 
child suddenly began to breathe more quickly, and with 
greater difficulty ; grew restless and tossed about in bed ; 
face bluish ; eyes wide open ; larynx drawn upward ; she 
braced herself against the bed with her hands ; perceptible 
cramps in the respiratory muscles ; predominant abdominal 
respiration ; the cough, which was very exhausting, was 
attended by a very peculiar hollow, somewhat hoarse sound; 
at times, also, metallic-sounding, piping, short coughs ; hands 
cold ; cold sweat on forehead ; spasmodic, small, very 
frequent pulse. The attack lasted five to six minutes ; after- 
ward the child sank back exhausted, coughed a few times 
loosely and easily, and fell into a stupefied sleep. She had 
five or six of these attacks for several consecutive nights, 



106 SPASM OF THE GLOTTIS. 

but of longer duration. Ipec. every two hours. The next 
day only one attack, which lasted only three to four minutes. 
During the day great debility, little appetite ; cough easy 
and loose, and even none at all for four or five hours at 
a time ; respiration normal ; two somewhat slimy, but 
otherwise healthy stools. The next night two rather lighter 
attacks, but next day still greater debility. Cuprum 9 in 
Sacch. /act., one powder ; if necessary another during the 
night. At midnight a very light attack, lasting only two to 
three minutes. The next day general health and appetite 
better. One dose Cuprum. No more attacks and soon 
restored to perfect health. (Dr. Hirsch.) 

'•A very delicate child, about one year old, had, since six 
nights, very violent attacks of spasm of the glottis without 
any coughs, either during the attacks or at other times ; they 
lasted five to ten minutes. Cuprum 9, three doses, one every 
evening, relieved the patient entirely." (Dr. Hirsch.) 

I have never seen any good results from Cuprum when 
given below the 12th centesimal dilution, and have generally 
given the Hahnemannian 30th with almost unvarying success, 
but I must add that, in my experience, cases in which 
Cuprum is indicated are not very common. 

Hughes says that in the paralytic variety Ignatia seems to 
be the remedy most homoeopathic to the paroxysm, but 
Baehr, after stating that this remedy is very much praised if 
the children suddenly lose their breath, which may be the 
lowest degree of spasm of the glottis, adds that " whether 
it will prove a proper remedy for spasm of the glottis has 
not yet been verified." Personally, I have not found it 
useful in idiopathic cases, though it has helped when the 
spasm was a mere incident in other diseases, say catarrhal 
croup or whooping cough. Of the symptoms one of the 
most characteristic is the difficulty of inspiration while 
expiration is easy, and this difficulty is suddenly experienced 
at midnight. All kinds of respiration alternate during sleep, 
short and slow, deep and light, intermitting and snoring. 
Also a sudden (not tickling) interruption of breathing in the 



SPASM OF THE GLOTTIS. 107 

upper part of the trachea, which irresistibly provokes a short, 
forcible cough in the evening. I have always used the 12th 
centesimal dilution, though possibly the 6th might have 
been still more effective. 

Lachesis has been successfully used, though Jahr says it 
has never afforded him much help in this disease, while 
Drysdale says that it is one of the two medicines which he 
has found, on the whole, most useful — arsenicum being the 
other. Personally, I am of opinion that, like Ignatia, this 
remedy is not indicated in idiopathic spasm of the glottis, 
but that it is often indicated when a partial, imperfectly- 
developed form of this morbid state supervenes on inflam- 
matory affections of the throat. 

Lachesis is indicated when the paroxysms occur during 
sleep ; the child, as it were, sleeps into an attack, and is 
roused gasping for breath. Or the paroxysms may recur 
after each nap. There is great sensitiveness of the larynx 
and trachea to the touch ; sense of constriction of the larynx, 
attended with dryness of the whole throat and mouth. Dr. 
S. C. Knickerbocker reports an excellent case in which the 
attacks were becoming more frequent and more severe, 
which was radically cured with two prescriptions' of Lachesis 
200. The attacks consisted of a sense of constriction of the 
larynx, attended with dryness of the whole throat and 
mouth — the attacks invariably occurred after sleeping — the 
" key-note " of Lachesis. 

" Plumbum is very closely related to Cuprum in every 
respect, except that the general strength is still more 
reduced. The symptoms of a spasmodic closing of the rima 
glottidis are more distinctly marked in the pathogenesis of 
this drug than in that of any other. We are amazed that 
Plumbum shouli not yet have been recommended for this 
disease, which, however, can only be cured by remedies which 
exert a deeply-penetrating, long-lasting influence over the 
whole organism." (Baehr.) Kane, too, recommends it the 
last of the few but well-chosen remedies with which he 
combats spasm of the glottis, but Searle, after remarking 



108 . SPASM OF THE GLOTTIS. 

that it has the mucous rale with sudden difficulty of breathing 
and asphyxia, adds, " but I do not know that it has ever 
been tried as a remedy for this disease." Here, too, I have 
had no experience, for I have never met with a case in which 
it seemed to be indicated. 

Dr. Alphonse Teste considers that Corallia rubra and 
Opium are "heroic agents against this disease," and as to 
the dose, he adds, " I prescribe Corallia at the thirtieth and 
Opium at the third dilution, a teaspoonful every two hours 
during the period of invasion ; every ten minutes during the 
exacerbations, and at intervals gradually increased when 
these are passed. The last-mentioned remedy is to be given 
every six hours, for a day or two after the resolution of the 
last attack." As spasm of the glottis frequently accompanies 
rachitis, Dr. Richard Hughes remarks that " the Corallia rubra 
so lauded by Teste, in its treatment may, from its calcareous 
nature, be suitable to these diathetic conditions as well as to 
the laryngeal spasms." Searle thinks that the Corallia rubra 
may be serviceable in cases which it is difficult to distinguish 
from whooping cough, and Farrington recommends Opium 
" especially after a fright," but I have never seen any benefit 
from the use' of Opium in this disease. 

The above are the leading remedies, but occupying a 
secondary rank are Zincum, Bromine, Nux vomica, Pulsatilla, 
Veratrum album, Lauroccasus, Spongia and Sulphur. 

Dr. Pemerl, of Munich, points out that *' when the spread 
of the spasms of the glottis to other respiratory muscles, to 
the tongue, to the upper and lower extremities, announces 
the transit to general convulsions, Moschus does not suffice 
any more, and we prefer the first trituration of Zinc-oxyd., 
either alone or in alternation with Moschus. Bromine has 
spasmodic closure of the glottis and constriction in the 
larynx, with a wheezing and rattling in the larynx; gasping 
and snuffling for breath ; cannot inspire deep enough ; the 
head and face are hot. Nux vomica is recommended by 
Kane and Duncan for reflected irritation from derangement 
of the digestive organs. Pulsatilla is said by Laurie to be 



SPASM OF THE GLOTTIS. 109 

often found successful in cases in which Moschus appears 
capable only of effecting a limited degree of improvement, 
but the present writer has never seen any" good effect from 
it, and it is doubtful whether it has ever been successfully 
used in unquestionable cases of spasm of the glottis. Vera- 
trum album is recommended by Jahr if spasm o the glottis 
sets in in company with other spasmodic symptoms ; Baehr 
advises it, together with Arsenicum album, if the disease 
attacks feeble children with marked symptoms of anaemia, 
and the writer has used it successfully, in the 12th centesimal 
dilution, when the patient was already cold and pale, with 
contracted pupils and protruded eyes. Laurocerasus when 
the child is pale and blue, with spasmodic constriction of the 
throat and congestion of the chest ; Farrington recommends 
it when the head is affected, which is rarely the case. Spongia 
is indicated when the child starts from sleep with constriction 
of the larynx, whistling respiration, the patient breathes with 
the head bent backwards ; this remedy may be used against 
the constitutional disease as well as the laryngeal spasm. 
Chamomilla is recommended for a sensation of oppression 
and slight constriction in the region of the larynx; constric- 
tion of the larynx with dyspnoea ; hot sweat on the head and 
face, especially during sleep. The child becomes stiff and 
bends backwards, kicks with his feet when carried, screams 
and throws everything off ; staring eyes, the child reaches 
and grasps for something, draws the mouth back and forth. 
The patient is peevish and irritable ; cries for things and 
pushes them away when given to him ; worse from anger or 
other violent emotions, from dentition and from exposure to 
cold winds. This remedy is not suited to well-developed 
cases, though I have seen it do good in such cases as the 
above. Of SulpJiiir, Bsehr says that it " may deserve atten- 
tion, although we shall take the liberty of doubting the 
homceopathicity of its asthmatic symptoms to spasm of the 
glottis until the fact has been corroborated by experience," 
but though I have never seen a case in which Sulphur would 
help during the acute attack, I have for many years given it 



1 10 SPASM OF THE GLOTTIS. 

in the 30th dilution to prevent a recurrence of the dreaded 
disease, thus following an invaluable hint of good old Jahr's. 
" In more than one case, however, I have radically removed 
a disposition to the return of the spasm by means of a dose 
of Sulphur." 

The remedy indicated by the ensemble of the symptoms 
should be given at the time of the attack as well as during 
the interval, but it is evident that, as the paroxysm lasts but 
a very short time, that it is not always possible to give the 
medicine. The same remark applies to v^ery many of the 
external applications recommended by various authors, for, 
in the vast majority of cases, the little patient is out of the 
paroxysm before the machinery is in motion, and in the 
matter of treatment, the writer relies very much on what is 
done during the interval. 

All external causes which may have the effect of irritating 
or exciting the nervous system should be carefully avoided, 
and moral causes are just as important as physical. There 
should be no sudden surprises, either playful or otherwise. 
The temper should be irritated as little as may be. All 
muscular effort should be carefully avoided, and Copland 
gives the excellent advice to avoid straining at stool. 

During the attack the patient should be placed in an 
upright attitude, so as to place the larynx in the easiest 
position possible, and all tight clothing should be promptly 
removed — or rather, tight clothing should never be put on 
children subject to spasm of the glottis. Vogel thus describes 
a simple operation much in vogue in Germany, which I have 
used with marked benefit : " In the instances where I 
happened to be present at the paroxysms, I introduced the 
index-finger into the mouth, carried it to the. posterior 
pharyngeal wall, elevated the spiglottis, and then touched 
the chordae vocales, by which marked acts of choking were 
at once induced, and then the well-known whistling inspira- 
tion followed. Lay people, of course, are unable to execute 
these manoeuvres, and I therefore content myself by showing 
them how retching may invariably be induced by pressure 



SPASM OF THE GLOTTIS. Ill 

upon the root of the tongue. The shock produced by 
inducing this act of retching is the only harmless remedy 
which will cut short the paroxysm." Dr. Morell Mackenzie's 
advice to " slap the patient on the back " should be carefully 
shunned. The same writer advises the dashing of cold 
water on the face, though Vogel says that he has seen no 
decided effects from cold affusions as well as from the forci- 
ble to-and-fro swinging in the air, so much in vogue with 
nurses. Steffen advises the full warm bath of from 90 to 
95 Fahr. combined with cold affusions over the head and 
neck, if the cyanosis assumes a high grade, consciousness is 
lost and general convulsive attacks set in, but the one 
objection to these procedures is the time involved in carry- 
ing them out. Romberg gives us the excellent advice to 
warm the prcecordia with hot napkins during the attack. 

Should Chloroform be used during the paroxysm ? Sir 
James Simpson proposed its use in this disease, and Dr. 
Charles West and other excellent English practitioners say 
that they have always secured prompt results without any 
ill effect whatever ; Dr. Duncan of Chicago, an excellent 
homoeopathic authority, endorses this recommendation. 
Morell Mackenzie says that " the inhalation of Chloroform is 
a very valuable remedy, but of course, it must be used with 
great care." Steffen, too, advises it to be used with great 
caution, and Dr. G. B. Wood advises the practitioner to 
bear in mind the hazardous character of this remedy. Vogel 
remarks that " it is too dangerous an agent to be left to the 
use of the lay attendant," and of course the physician could 
rarely be present to administer it during the paroxysms, and 
for this reason as well as for that given by Romberg, I am 
disinclined to use this agent. Romberg says, " it has been 
proposed to give Chloroform, but its effects upon the brain 
under such circumstances would probably render it unsafe.'' 

Should tracheotomy be employed as a last resort ? Mar- 
shall Hail, together with Wunderlich and other excellent 
German authorities, recommend it in the last emergency, 
when suffocation is taking place, and one of the latest and 



112 SPASM OF THE GLOTTIS. 

best of the English writers strongly advises it. " If the 
child appears to be sinking from the apncea, the trachea 
must, of course, be opened, and artificial respiration resorted 
to. Indeed, this should even be adopted by the practitioner, 
should he arrive shortly after the apparent extinction of 
life." But Steffen, a still higher authority in this particular 
disease, remarks that, " aside from the fact that, unless the 
patient happens to be in an hospital, this operation cannot 
always be performed quickly enough, I have never yet 
learned of any favorable result that has followed in spasm of 
the glottis," while Vogel says that " tracheotomy, which has 
been suggested as a dernier ressort, with which to save the 
life of the child, can never be performed, on account of 
want of time." Partial as are the French to tracheotomy, 
they have never, so far as I know, recommended it in this 
disease, and to me the reasoning of Romberg is perfectly 
conclusive, " nobody would attempt tracheotomy at the 
beginning of the attack, and if postponed too long no 
benefit can be expected from it." 

Vogel, Steffen, and all the great German writers on this 
disease, condemn the lancing of the gums, and Romberg's 
dictum may be taken as a fair specimen of their reasoning : 
" Scarification of the gums, in England considered a 
panacea, has not met with much countenance in Germany, 
as the excitement produced by the operation in the child 
outweighs the possible advantages of the operation." On 
the other hand, almost all the British and American writers 
approve of the operation, and we have seen that it was 
performed with success by Dr. Carroll Dunham, one of the 
strictest of Hahnemannians. I have never performed the 
operation, simply because I have not yet met with a case in 
which it was indicated. 

During the intervals of the paroxysms, and still more 
during the paroxysm' itself, there should be a good, long 
interval between the feeding hours of the child, and during 
the continuance of the disease the infant must not be penned, 
and I have heard of more than one death from ignorance or 



SPASM OF THE GLOTTIS. 1 1 3 

neglect of this simple and almost self-evident rule. Vogel 
advises that the child be kept as long as possible at the 
mother's breast, at least until it has cut the first six incisors. 
" If the fit comes on during sucking, either from the leather 
teat of the bottle or whilst the child is at the breast, it must 
be fed as Flesch insists, with a very small teaspoon, no matter 
how difficult at first it may be to get nourishment taken in this 
way." (Morell Mackenzie.) No food should be given soon 
after a paroxysm, for a second paroxysm may result from 
the mere act of swallowing, especially if particles of food 
enter the larynx. To children five or six months old I give 
beef tea, not essence of beef, but a weak preparation made 
by boiling finely minced beef with a considerable quantity 
of water, straining it through fine muslin or blotting paper, 
and I have seen good results from the addition of a soft- 
boiled egg to the diet. If the malady is complicated with 
rachitis, no farinaceous food whatever should be given ; such 
patients should be fed on meat and milk till they are at least 
seven years of age. Steffen advises the administration of 
Hungarian wine, or good, French red wine. 

A child subject to spasm of the glottis should never 
be disturbed during sleep, as, in many cases, the excite- 
ment of awakening brings on a paroxysm. Steffen thinks 
that children should not be kept warm in bed, and, in oppo- 
position to Elsasser, he asserts that lying down is no sort of 
disadvantage to children with craniotabes. 

I have found the cold sponging of the chest advocated by 
Dr. Richard Hughes more effective than the daily luke-warm 
baths of Steffen, and as the child gets older I recommend 
free sponging of the entire body with cold water every 
morning. 

To patients living in a city or large town, great benefit 
accrues from removal to the fresh, pure air of the country, 
and if the case is at all severe the patient should be at once 
removed. Still, as Vogel remarks, residence in the country 
by no means supplies a positive guarantee against the 
appearance of the spasms, and some of my worst cases 



114 SPASM OF THE GLOTTIS. 

occurred in children who had been all their lives in the 
country. Wherever the patient is the rooms should* be 
carefully and systematically ventilated, and Robertson recom- 
mends the free exposure of the infant out of doors for many 
hours daily, to a dry, cold atmosphere, and if the air be dry the 
colder the better. Dr. Marshall Hall says that the curative 
influence of change of air, and especially of the sea-breezes, 
is not less marked in this affection than in whooping cough. 

Aphorisms. 

i. Spasm of the glottis is a constriction of the muscles 
which narrow the glottis, accompanied by crowing inspira- 
tions, commencing suddenly, lasting a very short time, and 
ceasing suddenly. 

2. General convulsions and " carpo-pedal " spasms mark 
the advanced stage of the disease. 

3. Spasm of the glottis may depend upon an irritated 
disease of the brain, and also upon the scrofulous and rachitic 
constitutions — though its connection with rachitis is less 
clear than its connection with scrofula. 

4. The disease is most prevalent in northern countries and 
during the Winter season, and it is essentially a disease of 
childhood, though adults are. not exempt. 

5. Two- thirds of the sufferers from spasm of the glottis 
are boys. 

6. The disease is not really hereditary, though several 
children in the same family may suffer from it. 

7. Rachitis and spasm of the glottis often co-exist, but 
the first is not neccessarily the cause of the second, though 
rachitis of the thoracic bones may lead to the disease under 
consideration by inducing a deep-seated disturbance of nutri- 
tion and an increased irritability of the nervous system. 

8. Weaning favors the development of spasm of the glottis, 
and the irritation of teething may cause an outbreak of the 
disease. 



SPASM OF THE GLOTTIS. ITS 

g. As the child grows older the predisposition to the 
disease declines, and this depends on the increased size of 
the larynx and on the decreased irritability 'of the nervous 
system. 

io. The prognosis is more favorable in girls than in boys, 
and the older the patient the better the prospect of a 
successful issue. 

ii. The leading homoeopathic remedies are Sambucus, 
Aconite, Sanguinaria, Arsenicum album, Belladonna, Gelse- 
mium, Iodium, Chlorine, Cuprum and Ignatia amara. 

12. Chloroform must never be used by lay hands, and it 
is positively dangerous in cases depending on cerebral irrita- 
tion. 

13. The weight of evidence is against tracheotomy as a 
remedy in extremis. 

14. The patient must not be weaned during the continu- 
ance of the disease. 



CHAPTER V. 



Acute Catarrhal Laryngitis. 



The laryngeal diseases of young children are always very 
serious, as from the small size and delicacy of the organ in 
infancy, a comparatively slight inflammation greatly dimin- 
ishes its calibre. Again, the organ is absolutely essential to 
life, and but a slight disturbance of its healthy function is 
enough to endanger the very existence of the child, especially 
in those not rare cases in which there is a hereditary proclivity 
to laryngeal diseases. Laryngitis is somewhat frequent 
during infancy and childhood, and I cannot agree with M. 
Bouchut who considers it " a disease of slight importance," 
adding that its termination is " always favorable." On the 
contrary, it is frequently a serious disease, coming on sud- 
denly, attacking violently, and requiring skillful treatment 
from the physician and careful management from the nurse. 

The disease may be defined to be a catarrhal inflammation 
of the mucous membrane of the larynx, sometimes involving 
the submucous areolar tissue, giving rise to hoarseness or 
aphonia, stridulous and difficult breathing, cough and pain in 
the larynx — especially near the pomum Adami. Dysphagia 
is present in .very severe cases, and fever is an almost 
invariable accompaniment. If the inflammation is confined 
to the middle and lower parts of the larynx the cough will 
not be croupous, but if the epiglottis and rima glottidis are 
affected the cough will be decidedly croupous, and hence, 
many writers and practitioners speak of the disease as being 
a variety of croup. In reality, as Dr. W. V. Drury has well 
pointed out, every one, and especially every mother, should 
know that there are five or six different diseases with a 



ACUTE CATARRHAL LARYNGITIS. 117 

croupal cough — acute laryngitis, spasmodic laryngitis, 
membranous laryngitis, dipthertic laryngitis. 

Acute catarrhal laryngitis is often the result of repeated 
congestion of the larynx, and it may follow any irritatien of 
the mucous membrane, which irritation results in engorge- 
ment of the blood vessels, swelling and succulence of the 
mucous membrane, with copious generation of cells and an 
abnormal amount of mucus secretion. There are two 
varieties of acute laryngitis— acute catarrhal laryngitis and 
acute cedematous laryngitis — the first affecting the mucous 
membrane only, the second affecting the sub-mucous areolar 
tissue. The first mentioned also occurs in connection with 
some of the infectious fevers — measles, scarletena and variola 
— and, to some extent, it is present in most cases of bron- 
chitis and even in •pneumonia. 

Hippocrates makes some mention of a disease which was 
most likely laryngitis, but we find no other mention of it 
till the eighteenth century, when it appears to have been 
recognized by Drs. Mead and Millar, though the latter ob- 
scured his picture of the disease by confounding it with the 
spasm of the glottis to which his name has been attached. 
Later it was described by Dr. Hume in his Principia, and in 
1809 Dr. Baillie gave a very full account of it. The first 
dissection of the disease appears to have been made by Mr. 
Mayd in 1789, and forty years later Guersant first gave a 
clear account of its pathology. 

Dr. Ellis, of Auckland, New Zealand, says that this " is a 
disease far commoner in adults than in children ; still it 
does occur in children ; " but on our continent, at least, it 
is a very common disease amongst children, especially if the 
variety affecting the rima glottidis is taken into considera- 
tion. Acute catarrhal laryngitis occurs more frequently in 
children under five years of age than in those over that age, 
and Duncan remarks that of sixty-two well marked cases 
met with, in which the age was noted, fifty occurred in 
children under, and only twelve in those over that age; most 
of the fifty cases were under two years of age. It rarely 



Ho ACUTE CATARRHAL LARYNGITIS. 

attacks children at the breast, though it is not rare in chil- 
dren six or seven months old. It prevails in the fall, spring 
and winter months — especially in March and April — though 
severe cases are sometimes met with in summer. For 
obvious reasons, it is more frequently met with in boys than 
in girls. * 

Relaxing habits and confinement indoors undoubtedly 
predispose to this disease, and children resident in towns are 
more likely to be attacked than those living in the country. 
Long continued and violent crying often causes the disease, 
and it may follow the inhalation of dust or contaminated air. 
But the most common cause is " taking cold," and it often 
follows sitting in a draft of cold air, or permitting the child's 
feet to remain wet and cold. Quite often a severe coryza 
extends downwards to the larynx, and, but more rarely, the 
morbid process extends upward from the bronchial tubes. 
After a child has once suffered from acute catarrhal laryn- 
gitis other attacks are almost inevitable. 

The disease usually commences as a common cold ; there 
is chilliness followed by fever, with slight sore throat. 
Sneezing is often present, with slight hoarseness, all of which 
symptoms point to a somewhat mild catarrhal affection 
which may suddenly become a serious malady with symp 
toms of the gravest. Or, in the midst of excellent health, it 
may appear suddenly in the night, but, as a general rule, the 
above-mentioned prodomata are present. These symptoms 
persist for two or three days, when suddenly the voice 
becomes hoarse or disappears altogether, showing that the 
larynx is involved, for in that organ, and there only, is the 
voice formed. In the other class of cases, the attack is 
sudden, and the larynx is affected from the first. The child 
goes to bed apparently almost well, or with but a slight 
sneezing or coughing, when, after two or three hours of sleep, 
he wakes up very ill indeed. There is a hoarse and barking 
cough, ringing and croup-like, and accompanied by expec- 
toration ; it is paroxysmal and worse in the evening and 
during the night. The cough is wholly laryngeal, and some- 



ACUTE CATARRHAL LARYNGITIS. I 1 9 

times a little tough mucus is raised with relief of the local 
symptoms. If the patient is able to describe his feelings, 
complaint is made of a dull, aching pain in- the upper and 
front part of the throat, with a marked feeling of constriction, 
which prevents the patient from using the voice, even before 
it disappears; there is difficulty of swallowing, as much from 
the pressure of the inflamed larynx as from actual pharyn- 
gitis ; the larynx is felt to be enlarged, hot and tender on 
pressure, and the difficulty of breathing which is present 
from the commencement becomes aggravated. The little 
patient often puts the hands to the throat, and at times there 
are spasms of the muscles of the glottis, from which the 
disease gets the name of catarrhal croup. The child is very 
thirsty, restless and uneasy ; the skin is dry and hot ; the 
pulse full, and from 100 to 120 in the minute. This fever, 
with rapid pulse, hot skin and scanty urine, assumes the 
asthenic type, from carbonic acid poisoning, if the disease is 
unchecked. When croup-like cough, with markedly croupous 
breathing, hoarseness and fits of choking are present, it is 
almost impossible to distinguish the disease from pseudo- 
membranous croup. But after the symptoms have lasted for 
an hour or two, the breathing becomes normal or nearly so, 
the hoarseness almost disappears, moist rales appear in the 
chest, general perspiration breaks out, and the child falls into 
a sound sleep, usually accompanied by loud snoring. The 
most marked characteristic of the disease, then, is the parox- 
ysmal appearance of the stenosis of the larynx in the night, 
alternating with the symptoms of catarrh of the larynx 
during the day. This depends upon the fact that during the 
night the copiously-secreted mucus settles in the very narrow 
glottis, in fact almost closing the rima glottidis, at the same 
time adhering to the vocal cords. This, of course, gives rise 
to a rapidly-increasing impediment to respiration, till finally, 
after coughing and crying, and, it may be, vomiting, the 
mucus is removed for the time. Next morning the laryngeal 
stenosis has wholly disappeared, and is replaced by the 
catarrhal laryngitis with slight hoarseness, and, though in 



120 ACUTE CATARRHAL LARYNGITIS. 

some instances no second attack comes on, it frequently 
returns the next night. 

If the disease should prove uncontrollable, the breathing 
becomes still more obstructed, and inspiration requires an 
unusual effort, and is hissing and whistling. The cough 
becomes still more distinctive in its character. " It is brassy 
inits tone, terminates in a hissing noise, and begins similarly 
by a hissing inspiration in a muffled manner, because the 
lips of the glottis being thickened, irregular and rough, can- 
not be sufficiently closed to begin a sharp sound." (Hyde 
Salter.) " As the aperture of the glottis becomes narrower 
a terrible picture of distress presents itself, for strangulation 
seems to be imminent, ^and the patient tosses himself 
anxiously about, gasping for breath ; the face is pale and 
livid, the eyes start from their sockets, and the poor sufferer 
asks for fresh air, walks about, and goes to the window for 
it, and finally delirium and coma close the scene ; in fact, to 
use the expression of an able observer, he dies strangled." 
(Gibb.) Hoarseness remains for a number of days, and in 
the morning the cough is so violent and prolonged that it is 
sometimes difficult to convince the parents that the child is 
safe. I have seen cases in which, after repeated attacks of 
catarrhal laryngitis, an attack of true croup came on, under 
which the child succumbed, and this is quite likely to occur 
if such a patient is attacked with measles. In other cases 
again, chronic laryngitis resulted from repeated attacks of 
the acute disease. If the inflammation is very severe, 
oedema of the glottis may supervene, and the possibility of 
this untoward event must always be kept in view. 

There is a great difference of opinion as to the duration of 
this disease. Ellis thinks that it ought to disappear in from 
four to six days ; Vogel gives from three to eight days as the 
average duration ; Von Niemeyer says that it ought not to 
last more than a week ; Behr says that it lasts, at most, nine 
days ; J. Lewis Smith thinks that it disappears in from one 
to two weeks ; and von Riemssen gives for mild cases five to 
seven days, moderately severe, eight to fourteen days, while 



ACUTE CATARRHAL LARYNGITIS. 121 

the most severe, according to this writer, run from two to 
three weeks or longer. Other excellent observers take a 
more gloomy view, for DaCosta writes as follows : " The 
disease in its graver form runs a very rapid course. If, in a 
few days after its commencement, no improvement show 
itself, life does not last long. Sometimes death takes place 
on the first day of the attack. It rarely waits for the sixth." 
Morell Mackenzie is only a little less gloomy : " The acute 
stage seldom lasts more than three or four days, and I have 
seen a case terminate fatally in twenty-four hours. Death 
has been known to occur in seven hours. It is rare for the 
symptoms to remain serious after the fifth day, unless a kind 
of chronic oedema sets in." My own experience is that the 
duration of an acute case is from four days to a week, and 
decided danger is not far off if the disease is permitted to 
run on in a severe form much longer than a week, and this 
danger may take the form of true croup. If the disease is 
uncured, a chronic inflammation, or rather congestion, of the 
larynx remains, which is somewhat difficult of cure, though 
it must be admitted that spontaneous resolution, or resolu- 
tion as a result of therapeutic interference, is far more com- 
mon. When death takes place it is usually the combined 
result of spasm of the glottis and cedematous swelling, and 
the fatal event is often preceded by carbonic acid poisoning 
with its accompanying delirium. 

The thermometer does not usually show a marked rise in 
temperature during the day, but at night the increase is very 
marked, and the 99 or 99.5 of the day advances to 102 or 
even 103 . The appearance of laryngeal spasms, not being 
due to inflammation, does not cause much alteration in tem- 
perature. 

On examining the larynx it is found to be of a bright, cherry 
red color, which also extends to the tonsils and soft palate. 
The mucous membrane of these regions is dry and swollen, 
and the papillae are more prominent than in health. The 
epiglottis is of the same bright, red hue, and when felt by 
passing the forefinger down the throat it gives the sensation 



122 ACUTE CATARRHAL LARYNGITIS. 

of a round body of the size and consistence of a ripe cherry. 
As a general thing the whole of the pharyngeal mucous 
membrane is of the same bright, red color, and it is greatly 
congested and swollen. The vocal cords are of the same 
color, though they often have patches of a darker shade, 
and, later in the disease, a thick, adherent mucus covers all 
the mucous membrane, giving it a grayish tint. The dyspnoea 
and hissing respiration are caused by the swelling of 
the vocal cords, and not by the narrowing of the glottis as 
usually supposed. Gerhardt points out that the hoarseness 
is often the result of a partial paresis of the thyro aretenoid 
muscles, and this often precedes the congestion of the 
laryngeal mucous membrane, so that the old observation 
that hoarseness in a child is of more serious import than 
hoarseness in an adult may be looked upon as an established 
fact. 

The post-mortem appearances are confirmatory of those 
observed during life, though, as Felix Niemeyer remarks, 
the mucous membrane of the cadaver does not always reveal 
a degree of redness and vascular engorgement such as the 
violence of the symptoms during life would lead us to expect, 
and such as could then be demonstrated by laryngoscopic ob- 
servation. This, according to the same acute observer, is due 
to the richness of the laryngeal mucous membrane in elastic 
fibres, which, remaining distended by the blood contained in 
the vessels during life, after death contract, and expel the 
contents of the capillaries. The disease is a simple inflam. 
mation of the mucous membrane of the larynx, sometimes 
involving the sub-mucous areolar tissue, and accordingly 
there is reddening and swelling of the laryngeal mucous 
membrane, with a coating of mucus. ' It is rare that the 
larynx only is affected, for in almost every case the morbid 
process extends to the pharynx and trachea, producing 
very similar post-mortem appearances. At times the mucous 
membrane of the larynx is abraded from the removal of the 
ciliated epithelial cells, but true ulceration is rarely present ; 
if ulcers are present they are most likely syphilitic or scrofu- 



ACUTE CATARRHAL LARYNGITIS, ■ 1 23 

lous in their nature, and were present before the invasion 
of the acute disease. 

The diagnosis of this disease is easy, though sometimes it 
is difficult to distinguish it from pseudo-membranous croup, • 
for an apparently simple inflammation may really be the 
early stage of the plastic form of the disease. In catarrhal 
laryngitis the pharynx and tonsils are simply reddened ; in 
pseudo-membranous croup an examination of the fauces 
reveals patches or a continuous coating of pearly-white 
exudation on the soft palate, half arches, tonsils and pharynx. 
In catarrhal laryngitis the lymphatic glands of the neck are 
normal ; in pseudo-membranous croup they are often swollen. 
In catarrhal laryngitis the fever remits during the day, but 
in pseudo-membranous croup the remission, if any, is very 
slight. Indeed, it may be said that the entire morbid process 
of catarrhal laryngitis is remittent in its character, for, though 
the voice remains hoarse with a somewhat clangorous cough, 
the local affection and the fever are so slight that many 
children amuse themselves as if nothing were the matter. 
All this is completely reversed in pseudo-membranous croup, 
and both the local affection and its accompanying fever are 
much more pronounced. Catarrhal laryngitis is at first 
unaccompanied by expectoration ; and, as amendment sets 
in, a slight expectoration of. ordinary mucus appears; while 
the only sure diagnostic sign of pseudo-membranous croup 
is the expectoration of fragments or tubes of false membrane. 

Catarrhal laryngitis may be confounded with spasm of the 
glottis, but attention to the following points will at once 
clear up the difficulty : Catarrhal laryngitis comes on gradu- 
ally, while spasm of the glottis is marked by a sudden 
accession. Catarrhal laryngitis has hoarseness during the 
attack, which persists during the interval ; spasm of the 
glottis has no hoarseness at any time. Catarrhal laryngitis 
has a croupy cough, worse at night, better during the day ; 
spasm of the glottis has no cough whatever. Catarrhal 
laryngitis is unaccompanied by constitutional fever ; spasm 
of the glottis very rarely has fever. Acute catarrhal laryn- 



124 ACUTE CATARRHAL LARYNGITIS. 

gitis may be distinguished from whooping cough by the fact 
that the latter disease has no hoarseness, no inflammation, 
no fever and no thickening of the mucous membrane of the 
fauces. 

A great variety of opinions exist as to the prognosis of 
this disease, and that, too, amongst writers who are clearly 
describing the malady. Ellis thinks that the prognosis is 
" very unfavorable," and Dr. Morell Mackenzie says that " in 
early life, that is before the development of the larynx has 
taken place at puberty, the disease is always attended with 
great danger." According to the same author, it is more 
fatal in children than in adults, " more than four-fifths of the 
mortality occurring before the tenth year." On the other 
hand, Felix von Niemeyer says that " a fatal termination, 
uncomplicated by any other cause of death, is one of the 
greatest of rarities," an opinion which is echoed by Baehr ; 
von Riemssen, too, affirms that " a fatal result is extremely 
rare," while Steiner thinks that " the issue of acute laryngeal 
catarrh in recovery is the rule almost, without exception." 
My own experience is that the prognosis is generally favor- 
able. I have never known a fatal case under homoeopathic 
treatment, and I could scarcely imagine such a patient dying 
under the care of a well-read physician of our school. Favor- 
able signs are a diminution of dyspnoea, freer expectoration, 
and less difficulty in swallowing. The supervention of oedema 
of the larynx, fortunately rare, would greatly darken the 
prognosis. Very much depends upon the stage at which the 
physician is called in.; should coma be present, there is little 
hope. Previous allopathic treatment would diminish the 
chance of recovery, especially if emetics and mercurials have 
been used. Still, it must always be borne in mind that, even 
in healthy children, a simple catarrhal laryngitis may be 
converted into a true pseudo-membranous croup, and this 
possibility should always be present in the physician's mind. 
This is quite likely to take place in children suffering from 
measles or small-pox. 

In the treatment of this disease, Vogel's warning should 



ACUTE CATARRHAL LARYNGITIS. 1 25 

ever be present in the mind of the physician ; " Pseudo- 
croup should never be regarded slightingly, even in its 
mildest form, for very gradual transitions into the genuine 
croup happen, and, after the fatal termination of which, we 
may, when too late, regret having carelessly treated the 
first hoarseness." During the entire course of the disease, 
the little patient should be kept in bed, especially if the 
weather is cold or wet, and this should be rigidly enforced 
till there is no trace of hoarseness left. The atmosphere of 
the sick chamber should be uniform, moist and warm, and to 
secure uniformity a thermometer should invariably be used. 
The warmth and moisture may be secured by the genera- 
tion of steam in the apartment, and then the affected 
larynx will be kept from further irritation, for the warm 
moisture prevents the drying of the mucous secretions of 
the affected parts during sleep, and the patient is spared the 
terrible attacks of dyspnoea which result from this inspissa- 
tion. The inflamed organ shouldbe rested. On no account 
should the patient speak ; an ample experience convinces 
me that silence is often absolutely indispensible to a cure. 
I have seen good results from a warm compress to the 
throat, but only evil from the applications of pounded ice, 
introduced, I believe, by Dr. John Mason Good. The diet 
should be bland and demulcent, and if dysphagia is at all 
marked, nutrition by the rectum should be at once com- 
menced. 

In the prevention of acute catarrhal laryngitis the prac- 
titioner will soon discover the value of Felix von Niemey- 
er's advice. " It is advisable rather cautiously to habituate 
children to the causes of this disease, than to enervate 
them by a systematic over-protection, which tends to 
increase the liability to its attacks upon every trifling occa- 
sion." To this end, the child must not be shut up in the 
house merely because it has once had an attack of 
this disease. The little one should be in the open air every 
suitable day, and, when in the house, close and over-heated 
rooms, especially bed-rooms, should be sedulously avoided. 



126 ACUTE CATARRHAL LARYNGITIS. 

But, when in the open air the child should not dawddle 
round in the manner too often seen, but should be en- 
couraged to indulge in active exercise. Flannel under- 
clothing should be worn in winter and merino in summer, 
and the underclothing should come high up on the neck, but 
the neck should not be burdened with additional shawls and 
mufflers. F. von Niemeyer tells us that a silk ribbon worn 
about the neck has the reputation of a sympathetic prophy- 
lactic, and, as no harm can possibly result, it would be well 
to test the somewhat eccentric recommendation. Sponging 
the entire body with tepid salt water every morning has a 
very excellent effect, though if the throat and neck are 
washed with cold water the result is still better. Von 
Riemssen advises the use of the rubbing wet sheet of the 
hydropaths, and I can endorse the recommendation after 
a long experience of its good effects. " In such cases it is 
well to have the whole body rubbed every morning with a 
large sheet, which has been previously dipped in cold water, 
and carefully wrung out. As the patient gets out of bed his 
night linen is removed, and the sheet, which is held spread 
out, is thrown around him from behind, so as to cover the 
head, but not the face, and the whole body down to the feet. 
A gentle, rapid friction of the skin by rubbing with the 
sheet will diminish the unpleasant impression from the cold 
moisture. After one or two minutes of this friction the wet 
sheet is removed, a warm, dry one is thrown about the body 
in the same way, and the body is dried. The patient then 
puts on his clothes, and immediately takes out-door exercise, 
whatever the weather. If the skin be very delicate, I 
modify the treatment by at first giving the water, into which 
the sheet is dipped, a lukewarm temperature (about 86° F.), 
and then lowering the temperature two degrees daily, until 
it reaches that of spring water (50 to 56 ). This treatment 
I have adopted for several years, with the best results for 
children as well as adults, and the patients never catch cold, 
if the rubbing be done in a warm room with the feet resting 
on a woolen rug. After using this treatment for eight days 



ACUTE CATARRHAL LARYNGITIS. 12J 

the patient may be allowed to wear less clothing. During 
the winter he may continue to use a fine woolen under- 
jacket, notwithstanding the frictions, but in ,the spring this 
garment must by all means be discarded, and about this 
time the cold frictions are to be resumed, if they are not 
employed both summer and winter, as is advisable in the 
case of children." Whenever at all practicable, children 
subject to catarrhal laryngitis should spend at least a portion 
of each summer at the seaside, for nothing diminishes the 
sensitiveness of the skin and respiratory mucous membrane 
like the exhilarating air of the sea-coast. 

In almost every case Aconite is the first remedy indicated, 
though Baehr remarks that " upon the whole, this remedy 
does not seem often indicated in simple catarrhal affections, 
except, perhaps, in the case of children in whom the febrile 
symptoms assume a different shape from what they do in 
full grown persons." He adds, however, that " for catarrhal 
croup it is undoubtedly the best remedy, which, however, 
ceases to be indicated if the physician be not called till the 
second or third day of the disease." It is emphatically the 
remedy when the disease is caused by exposure to keen, dry, 
cold air, and as soon as the laryngeal inflammation is lighted 
up, this remedy, if given in repeated doses, will often cut 
short the most severe attack. The skin is hot and dry, 
with full, quick and bounding pulse ; the voice is rough, 
hoarse and tremulous (with Belladonna and Bryonia the 
voice is nasal cr raised) ; painful sensitiveness of the larynx, 
with aggravation on coughing or speaking ; short, dry cough, 
with constant irritation ; during the day the cough is short 
and panting, at night it is rough and hollow ; accompanying 
this cough there is expectoration of scanty, whitish mucus ; 
the face and eyes are red and flushed ; great thirst is present; 
the sleep is broken and restless, and the entire nervous 
system is irritable. I have had the best results from the 4th 
or 5th decimal triturations of the root of Aconite, but it 
must prove curative in all dilutions and preparations. 

Sanguinaria is indicated by dryness of the throat, with 



128 ACUTE CATARRHAL LARYNGITIS. 

soreness, swelling- and redness ; sensation of swelling in the 
larynx and expectoration of thick mucus ; tickling in the 
throat in the evening, with slight cough and headache ; dry- 
cough, awakening him from sleep, which did not cease until 
he sat upright in bed, and flatus was discharged upwards 
and downwards ; tormenting cough, with expectoration ; 
circumscribed redness of the cheeks ; continued severe 
cough, without expectoration ; pain in the breast, and cir- 
cumscribed redness of the cheeks. I have used Sanguinaria 
successfully in many cases of laryngitis, and I look upon it 
as being the leading remedy in this disease, Aconite not 
excepted. I have generally used it in the form of an 
acetous syrup, as directed in the chapter on pseudo-membra- 
nous croup. 

Spongia is a most important remedy when croupous 
breathing appears in the course of the disease. Laurie says 
that it should, in the generality of cases, be administered 
six hours after the last dose of Aconite, and Bsehr thinks 
that it is the principal remedy for this disease when accom- 
panied by distinct symptoms of oedema of the mucous lining 
of the glottis. The cough is dry, barking and hollow, coming 
on in paroxysms, especially at night, with shrill and wheez- 
ing breathing ; when there is expectoration it is only in the 
morning (with Hepar there is expectoration in the morning 
and during the day) ; it is improved by eating and drinking, 
worse when sitting erect, from motion and exertion (the 
cough of Hepar is worse when lying). The larynx and upper 
part of the trachea are painful and sensitive to the touch, 
the hoarseness is very marked and the patient speaks with 
difficulty. Bsehr remarks that Spongia is likewise appropri- 
ate, if the croupous sound of the cough still continues, and 
lumps of a tenacious, yellow mucus are expectorated. I 
have had the best results from the lower triturations from 
the 3d to the 6th decimal. 

Hepar is very similar to Spongia, but there is rattling of 
mucus in the larynx from the commencement ; the cough is 
moist with great hoarseness, and slight suffocative spasms 



ACUTE CATARRHAL LARYNGITIS. 1 29 

are present, Hepar is worse indoors and in the morning, 
while Spongia is better outdoors and in the morning. Laurie 
remarks that Hepar may be selected to follow Aconite in 
preference to Spongia, if the fever and burning heat of the 
skin continue, notwithstanding the previous administration 
of Aconite. I have had the best results from this remedy in 
the 4th or 5th decimal triturations. 

Tartar emetic is indicated when there is hoarseness from 
the very beginning of the laryngeal inflammation, a hard and 
ringing cough, or paroxysmal fits of coughing, with suffoca- 
tive arrest of breathing and profuse secretion of mucus. 
Hartmann gives this remedy " if the inspirations should 
evince a paralytic condition of the lungs," and in this state 
Tartar emetic will help unless the patient should be beyond 
the reach of help. I have succeeded best with the 3d or 
4th decimal triturations in repeated doses. 

Belladonna is, according to Dr. Duncan, of Chicago, the 
leading remedy in simple, uncomplicated cases of this disease, 
and we thank that excellent observer for pointing out a fact 
which, though recorded in our literature, had passed from 
the professional mind. Very many cases are simply conges- 
tion in the first place, and, if Belladonna is promptly given, 
the results are very striking. Violent stinging pains in the 
larynx are present, with dry spasmodic cough, coming on in 
paroxysms, aggravated particularly in the evening and before 
midnight. Croupous breathing with hoarseness is present, 
and the voice is low and feeble— in some severe cases this 
proceeds to complete aphonia. The pharynx and tonsils 
usually participate in the inflammatory action, and deglutition 
is difficult and painful. Fever is present with disposition to 
perspire and to sleep ; the pulse is full and bounding. 
Laurie says that Belladonna is not to be administered in 
cases in which it has been previously employed, as, for 
instance, if the affection of the windpipe occurred immedi- 
ately after an attack of pure scarlet fever. I have commonly 
used Belladonna from the 6th decimal to the 12th centesimal 
trituration, though doubtless it would be effective in almost 
any dilution. 



130 -ACUTE CATARRHAL LARYNGITIS. 

Mercurius solubilis is said by Bsehr to act similarly to 
Belladonna in this disease, though I have never been able to 
see the resemblance. There is chilliness and great sensitive- 
ness to cold, with frequent paroxysms of dry, burning heat, 
alternating with copious perspirations which do not afford 
relief ; the larynx is sore, the patient is hoarse, but there is no 
loss of voice ; the dry, distressing cough occurs principally 
at night, and the catarrhal inflammation extends to the eyes, 
nose, pharynx and even to the mouth. I have had the best 
results from this remedy in repeated doses of the 4th to 5th 
decimal triturations given dry on the tongue. 
' Bryonia is an excellent remedy to follow Aconite, or, in 
mild cases, from the commencement. The cough is spas- 
modic and suffocating, especially after midnight, with expec- 
toration of yellowish mucus, hoarseness with rattling of 
mucus in the larynx, and tenderness of the larynx on 
pressure. In young children I have usually given the 12th 
centesimal dilution, but, on the whole, Bryonia is not so 
useful in children as in adults. 

Phosphorus has fever with hoarseness and dry spasmodic 
cough, with stitches in the larynx and constriction of the 
throat. The voice is trembling or hissing (in Bryonia it is 
raised or nasal), or there may be complete extinction of the 
voice. I have had the best results from the 12th centesimal 
dilution, and it is an excellent remedy to follow Aconite. 

Arsenicum album is indicated by glowing fever-heat with 
constant thirst ; general debility with a prostrate feeling in 
the whole body ; burning pain in the larynx, increased by 
deglutition, which is difficult ; short, dry, hoarse cough in 
rapid paroxysms, with violent action of the pectoral muscles 
during an inspiration. Arsenicum acts well in all dilutions ; 
I prefer the 12th centesimal. 

Lachesis is a valuable remedy when the larynx is raw and 
dry and very sensitive to the touch. No laryngeal spasm is 
present, but the patient is hoarse, with a feeling as though 
something had to be hawked up, and a good deal of pain 
and difficulty is experienced on swallowing. Lachesis is 



ACUTE CATARRHAL LARYNGITIS. I3I 

often indicated after Hepar, and I have had excellent results 
from the 12th centesimal dilution. 

Minor remedies are Nux vomica, useful during the decline 
of an attack after the fever has abated, when there is still an 
evident sense of constriction during breathing, with a 
constant tickling, hawking cough with tenacious expectora- 
tion ; Hyosciamus, useful when after the cure of the laryngeal 
inflammation, a spasmodic cough, only at night, remains to 
harrass the patient ; Argentum nitricum, when the disease 
tends to assume the chronic form, with swelling of the 
posterior wall and lining of the larynx, with hoarseness and 
loss of voice, continual and vain efforts to swallow, with pain 
and soreness in deglutition, much hawking, considerable 
muco-purulent expectoration or titillation in the larynx, with 
dry, spasmodic cough ; Pulsatilla when the patient is chilly 
with titillating cough, excited by a sensation of scraping and 
roughness in the throat, spasmodic and setting in more 
especially in the evening and when lying down, better on 
sitting up, commencing again on lying down, and some- 
times increasing to suffocation ; lastly, Hartmann advises 
Ipecacuanha or Sambucus if, after the abatement of the 
fever, local symptoms should still remain with anxious and 
hurried breathing. 

Aphorisms. 

1. Acute catarrhal laryngitis, also called catarrhal croup, is 
simply a catarrh of the larynx, which assumes the croupous 
form when the epiglottis and*rima glottidis are involved. 

2. The duration of the disease is from four days to a week, 
and, should it last longer than a week, there is a danger of 
the advent of pseudo-membranous croup. 

3. Even in healthy children a simple catarrhal laryngitis, 
apparently devoid of danger, may be converted into true 
croup — one of the most serious of diseases. 

4. Even in its mildest form, acute catarrhal laryngitis 
should never be regarded slightingly. 



132 ACUTE (EDEMATOUS LARYNGITIS. . 

5. The silence of the patient is often indispensible to a 
cure. Rest the inflamed organ. 

6. Acute catarrhal laryngitis is best prevented by gradually 
accustoming children to the causes of the disease, and by the 
judicious use of hydropathic appliances. 

7. The leading homoeopathic remedies are Aconite, San- 
guinaria, Spongia, Hepar, Tartar emetic and Belladonna. 

8. Belladonna, one of the chief remedies, has been too 
much neglected hitherto ; Sanguinaria will remove the pre- 
disposition to the disease. 



CHAPTER VI. 



Acute (Edematous Laryngitis 



This disease is not very common among children, and, as 
it occurs under varying conditions, many excellent writers 
consider it a mere symptom supervening on the morbid 
states, but as Prosser James remarks, " it is a condition so 
important as to deserve to rank separately as a disease." 
Its rarity is accounted for by the fact that in young children 
there is very little submucous areolar tissue in the larynx, 
consequently very little field for submucous effusion during 
inflammations of that organ. 

Acute cedematous laryngitis may be defined to be an in- 
flammation of the submucous areolar tissue of the larynx, 
resulting in infiltration of serous, sero-purulent or purulent 
fluid, accompanied in serious cases by stridulous breathing, 
orthopncea, and dysphonia or even aphonia. The older observ- 



ACUTE CEDEMATOUS LARYNGITIS. 1$$ 

ers considered that it was non-inflammatory in its nature — in 
fact a pure dropsy — but later investigations have conclusively 
shown that inflammatory oedema of the larynx is much more 
frequent than non-inflammatory infiltration. The older 
name — oedema of the glottis — has been gradually abandoned 
for the more appropriate one of oedema of the larynx, for 
the glottis is not specially the seat of this affection. Some 
writers apply the term submucous laryngitis to this disease, 
but Trousseau objects to it on the ground that it conveys 
the idea of an inflammatory malady, although the name he 
proposes — angine laryngee oedemateuse — is open to a similar 
objection. Bouilland proposed the term laryngitis phleg- 
monosa, indicating the identity of the morbid process with 
the phlegmonous inflammations of other mucous membranes, 
and von Riemssen has definitely adopted the term. 

(Edematous laryngitis most frequently occurs in feeble 
children, and at first it may be mistaken for a ' cold '; as the 
disease advances, croup presents itself to the mother's mind. 
Children who have chronic tonsillitis are liable to it, and in 
such cases the disease commences in a very insidious manner. 
It may come on when the little patient is recovering from 
measles or scarlatina, and in the latter disease it has been 
more frequently observed in patients who have had the dis- 
ease in a mild form than in those who have had a severe 
attack ; indeed, I have come to look for it, especially in 
patients in whom the disease has been wholly without erup- 
tion. It may be developed during the course of albuminuria, 
and, indeed, in connection with any disease on which 
anasarca may supervene. It accompanies tuberculous 
disease of the larynx, and in scrofulous subjects suffering 
from erysipelas of the head and face, the physician should 
be on his guard that it does not prove a suddenly fatal 
complication. Sir Thomas Watson says that he has known 
such an inflammatory oedema to arise from a mercurial sore- 
throat in a broken-down constitution. 

Acute oedematous laryngitis is either primary or seco7tdary, 
though Dr. Paul Guttmann of Berlin opposes Sestier, Trous- 



134 ACUTE (EDEMATOUS LARYNGITIS. 

seau, Mackenzie, Bsehr and almost the entire profession by 
stating that "oedema of the larynx is invariably secondary." 
The disease is said to be primary when it attacks children 
previously healthy ; secondary when it affects those already 
suffering from disease. Sestier, who, more than any one, is 
competent to speak with authority on this disease, in one 
hundred and ninety cases found thirty-six primary, and a 
hundred and fifty-four secondary. Again, the disease is 
typical, when originating in the larynx, contiguous when it 
spreads from the pharynx or other adjacent parts, and 
consecutive when it depends upon some organic disease of 
the larynx. Again, the morbid state may be either acute 
or chronic, and at times it assumes an epidemic form, and I 
remember an epidemic of scarlatina, marked by the preva- 
lence of oedema of the larynx in the contiguous form — but 
only when the scarlatina was declining. The mechanism of 
the disease will readily be understood when we reflect that 
the submucous tissues are in a state of sub-acute inflamma- 
tion, that effusion has taken place, and that the resulting 
swelling obstructs respiration, and, as the swelling is usually 
greatest in the epiglottis and upper part of the larynx, 
inspiration is more difficult than expiration. " Considering 
the manner in which thedisease originates, the most correct 
explanation seems to be that a suppurative process in the 
neighborhood of the glottis causes oedema in the same man- 
ner in which a chancre causes within a few hours an excessive 
oedema of the prepuce." (Bsehr). Again, the disease is 
supra-glottic or sub-glottic, the latter being an inflammatory 
oedema of the parts below the vocal cords, more difficult of 
diagnosis than the supra-glottic variety, and, when operative 
measures are indicated, calling for tracheotomy rather than 
the scarifications so effective in the supra-glottic variety. I 
propose considering in this chapter the non-inflammatory 
form of oedema of the larynx, as well as the inflammatory, 
although the treatment necessarily varies with the cause of 
the morbid state. 

None of the medical writers of antiquity describe this 



ACUTE CEDEMATOUS LARYNGITIS. 1 35 

disease with anything like clearness, and this is not to be 
wondered at when we reflect that they merely described the 
symptomatic appearances observed during life, and that they 
•were almost wholly ignorant of morbid anatomy. In the 
year 1765, Morgagni, in his famous work, De Sedibus et 
Cansis Morborum, first clearly described the post-mortem 
appearances, and later Boerhaave and his commentator, Van 
Svvieten, added to the store of knowledge. In 1801, Bichat 
described the malady as being wholly unique — " a particular 
kind of serous swelling that does not occur in any other 
situation '' — from which it is evident that he did not clearly 
understand the mechanism of the disease. In 1808 Bayle 
presented to the Medical Society of Paris his Memoir e sur 
r cede me de la glotte on angine larynge'e cedemateuse, which 
constitutes the starting point of a scientific knowledge of this 
disease. I ha^e not had access to the original, and authors 
differ as to the true nature of his views, for, while von 
Riemssen states that " Bayle's cedema glottidis is a serous 
infiltration of the submucous connective tissue, non-inflam- 
matory in its origin,"^ his countryman, Trousseau, says, " I 
repeat, that you will almost constantly see cedema of the 
larynx depending on inflammation, a fact which Bayle 
established and was the first to describe." Finally, in 1852, 
Sestier gave us a standard work, including references to 245 
cases, not including cases of scald-throat. Still later, Gibb, 
Mackenzie and von Riemssen have systematized our knowl- 
edge, and at the present time the disease is almost as well 
understood as any other laryngeal affection. 

The disease is somewhat rare in childhood, though there 
is reason to believe that many fatal cases are attributed to 
other diseases. In 215 cases Sestier found only five in 
children under five years of age, one of them being a new- 
born infant, and twelve cases between five and fifteen years. 
Again, in 245 cases, Sestier noted only two primary cases in 
children, and in two other cases, between the ages of four 
and six years, the disease arose by propagation from inflamed 
neighboring parts. 



t$6 ACUTE (EDEMATOUS LARYNGITIS. 

Acute cedematous laryngitis may supervene on a slight 
attack of local inflammation, as catarrhal pharyngitis, or, 
more frequently, erysipelas of the pharynx, though, as a 
general rule, it follows deeper seated affections of the larynx. 
Indeed, Sestier asserts that " simple inflammation" is 
the cause of oedema of the larynx in only six per cent, of all 
his cases, while in twenty per cent, of his cases propagation 
took place from the pharynx, and the pharyngitis was in 
many cases moderate and even slight. 

GEdematous laryngitis almost constantly commences with 
a chill, even when it appears as an intercurrent disease. 
The chill alternates with flushes of heat, and soon the skin 
is hot, the pulse full and bounding, and the face red and 
flushed. Deglutition is difficult, partly from the pharyngitis 
so frequently present, and partly from the swollen epiglottis 
permitting food to enter the larynx. The external parts are 
swollen in both the primary and secondary varieties of the 
disease, t and the swelling is simply the serous effusion 
following sub-acute inflammation. The patient complains of 
sore throat, and one of the misleading features of the 
malady is that, on examination, the tonsils and pharynx 
appear to be the seat of the disease. Often the patient,, if old 
enough to describe his feelings, complains of a pricking, burn- 
ing pain in some particular part of the larynx, and this pain is 
increased by deglutition and accompanied by a slight, 
irritative cough without expectoration. But soon the voice 
gets rough and hoarse, and this rapidly-increasing hoarseness 
soon passes into almost complete aphonia. At the same 
time complaint is made of pain as if a piece of wood or 
other foreign body were wedged in the larynx, and this gives 
rise to repeated efforts, by swallowing or by coughing, to clear 
the throat of the offending substance. But the harsh and pain- 
ful cough only results in the difficult expectoration of a little 
viscid mucus, which brings no relief. The most prominent 
symptom, however, is an impediment to respiration, sometimes 
increasing gradually,at other times with such frightful rapidity 
that the fatal result takes place almost immediately. At 



ACUTE (EDEMATOUS LARYNGITIS. 1 37 

first the respiration is whistling and wheezing, at an ad- 
vanced stage it is rasping and sawing. At the commencement 
of the morbid state the oppression is greatest during inspira- 
tion, which requires considerable effort and is accompanied 
by a kind of snoring noise, especially during sleep. Expira- 
tion, of course, is performed more readily than inspiration, 
for the swollen membrane closes like a valve against the 
entrance of air, but readily permits it to pass out. As the 
disease advances, however, expiration, hitherto easy, noise- 
less and hardly perceptible, becomes difficult and the dysp- 
noea rapidly increases. There is, however, even in cases in 
which permanent obstruction is present, the same tendency 
to remissions and exacerbations that characterizes almost all 
affections of the larynx, though the paroxysms may last as 
long as ten to fifteen minutes, during the whole of which time 
suffocation appears to be imminent. During the paroxysm 
the patient stands up from the bed and instinctively makes 
for the window with mouth wide open, agonizing for breath. 
The face is livid and cool, the nostrils are distended, the 
eyes seem to start from the head, the whole body is tremb- 
ling and convulsed, and the skin is bathed in perspiration, the 
cough becomes less frequent, and as the disease advances it 
disappears altogether, as the patient cannot inflate the lungs. 
As the carbonic acid poisoning advances the face becomes of a 
dusky, bluish hue, delirium appears, during which the sufferer 
tears at his neck in a kind of frenzy, and unless prompt 
relief is given he dies strangled. 

Should a favorable change take place, all the symptoms 
abate ; the difficulty of breathing diminishes, though it still 
remains somewhat embarrassed, especially during inspiration ; 
the cough becomes easier and more sonorous ; the voice once 
more becomes audible. It is some time before the little 
patient recovers from the effects of such a storm, and he 
must be carefully guarded against relapses. 

From first to last the disease, in its primary form, may last 
from three to five days ; as an intercurrent disease, it may 
prove fatal in a few hours. B?ehr says that the affection may 



138 ACUTE (EDEMATOUS LARYNGITIS. 

last from twelve hours to upwards of a week, and von 
Riemssen holds that highly-acute diffuse infiltration runs its 
course under the most stormy manifestations, and may cause 
death within a few hours or even minutes, through closure 
of the laryngeal entrance, if the right help is not afforded 
at the right time. Prof. George B. Wood thinks it probable 
that life is sometimes suddenly terminated by the superven- 
tion of spasm of the glottis, and the writer has seen cases in 
which this has actually occurred. 

Scald-throat, as it is popularly called, is a very common 
and very fatal form of cedematous laryngitis among the chil- 
dren of the laboring classes in England, and indeed in every 
country in which tea is an ordinary beverage. The accident 
usually happens to young children in the mistaken attempt 
to drink boiling water from the spout of the tea-kettle. The 
boiling water rarely reaches the oesophagus, for it is expelled 
by the spasmodic action of the muscles of the pharynx, but 
it has had time to come in contact with the inside of the 
mouth, the epiglottis and aryteno-epiglottidean ligaments. 
Probably the screaming, caused by the acute pain, causes a 
sudden inspiratory effort which draws the boiling water, and 
still more readily the heated steam, towards the larynx. 
Even when the larynx itself is not scalded, it soon becomes 
involved by extension of inflammation from the pharynx. 
Sometimes a deceitful calm of an hour or two follows the 
scald, when suddenly the laryngeal symptoms are developed, 
and the state is at once alarming in the extreme. More 
commonly, hoarseness and dysphagia appear at once, accom- 
panied by inflammatory fever, and this is followed in a few 
hours by oedema of the larynx, with difficult inspiration, 
hoarse, croupous breathing, and even spasm of the glottis. 
The morbid state marches on with frightful rapidity, the face 
becomes bluish, the hands and feet cold, the breathing more 
and more oppressed, the voice becomes extinct, and death 
takes place by suffocation. 

The post-mortem appearances in cases of scald-throat are 
those of intense inflammation of mucous membrane of all 



ACUTE (EDEMATOUS LARYNGITIS. 1 39 

the affected parts, and especially the mucous membrane of 
the epiglottis and of the aryteno-epiglottidean ligaments is 
thickened from effusion into the sub-mucous areolar tissue. 
Sometimes the opening of the larynx is quite closed, but the 
oedema never extends below the vocal cords. When death 
is very speedy, and speedy deaths are very common here, the 
mucous membrane below the rima glottidis may be quite 
normal, but when the patient has survived for some days the 
trachea and bronchial tubes are inflamed, and the lungs 
congested, or even hepatized. 

Not even Wunderlich, with his tireless industry, has given 
us any observations as to the temperature of the body in 
this dreaded disease, and personally, when I had a case, I 
thought more about the lancet than the thermometer. 

The inflammation present in cedematous laryngitis is of a 
low grade, and the effusion is produced in the sub-mucous 
areolar tissue as the result of inflammatory action in that 
membrane, or as the result of inflammation in adjoining 
parts, as Bsehr has so well pointed out. As a general rule, 
the affected parts have the usual red hue of inflammation, 
but about the entrance to the larynx they are often trans- 
parent, fluctuating and of a pale-yellow color, especially the 
parts well supplied with areolar tissue, as the duplicature of 
the aryteno-epiglottidean ligament. These bulge out in two 
loose and pendulous rolls extending backwards to the 
pharynx, while the bloated epiglottis projects high above 
the root of the tongue. Sometimes but one of these 
ligaments is affected, and a single transparent swelling closes, 
more or less, the entrance of the glottis. Sometimes, but 
rarely, the sub-mucous tissue of the vocal cords is affected, 
and the sub-glottic form of the disease, so well described by 
Sir George Duncan Gibb, is almost as rare, simply because, 
as he points out, "the sub-mucous tissue at the upper part 
of the larynx is loose, and quickly admits of infiltration and 
swelling, or oedema, during inflammation ; but below as well 
as in the trachea, it is less in quantity, and of a more dense 
quality, therefore, inflammation is not succeeded so rapidly 



I40 ACUTE CEDEMATOUS LARYNGITIS. 

by sub-mucous effusion as it is by exudation of lymph upon 
its surface." At times the oedema extends down the trachea, 
but Sestier detected it only seven times in 132 cases of 
oedema of the upper air passages. Very commonly, the 
neighboring muscles are saturated with the serous or sero- 
purulent fluid. Generally the effused fluid is sero-purulent, 
for pure serum is found only in the foudroyante cases ; 
according to Sestier blood is often mingled with serum in that 
very class. In the more chronic cases the fluid is quite 
purulent. 

The diagnosis of cedematous laryngitis is surrounded by 
difficulties, yet much depends upon the disease being recog- 
nized at an early stage. Some physicians include all 
laryngeal diseases of children under the generic name of 
" croup," and such a wholesale ignoring of pathology must 
result in a largely-increased mortality in this class of diseases. 
M. Thuillier's test, insisted on by all practitioners who have 
studied the disease, is almost decisive as to the existence of 
the supra-glottic variety, though, for anatomical reasons, it 
affords us little or no help when the disease is sub-glottic. 
By simply depressing the tongue, the epiglottis rises as a 
pale or reddish, pear-shaped swelling behind the root of the 
tongue. Then when the index-finger is rapidly but gently 
passed into the larynx, the cedematous swelling can be 
distinctly felt. With one hand the physician should press up 
the os hyoides so as to bring the glottis more within reach, 
while the forefinger of the other hand is engaged in explora- 
tion, but, as already remarked, we can only detect the 
cedematous swelling of the epiglottis and aryteno-epiglotti- 
dean ligaments. Dr. George B. Wood thinks that this mode 
of examination must be difficult, and that it might possibly 
aggravate the inflammation, but in practice one almost 
always succeeds, though with varying facility. Trousseau 
observes that exploration by the finger must be practiced in 
a very careful manner, and he adds that while he was exam- 
ining the throat of a woman in the most guarded possible 
way, he induced a suffocative seizure, which very nearly 



ACUTE (EDEMATOUS LARYNGITIS. 141 

proved fatal. In adults the laryngeal mirror would aid 
much in the diagnosis, but it is difficult to use it in children. 

Acute cedematous laryngitis is very likely to be confounded 
with croup, and in very many points there is a very strong 
resemblance. It resembles croup in the difficulty of breath- 
ing, the suffocative fits and the cough, the hoarse voice, and 
the noisy, stridulous inspiration, and even in the intermis- 
sions between the paroxysms, which, indeed, are common to 
all laryngeal diseases. But cedema of the larynx chiefly 
occurs as an inter-current disease in children suffering from 
some malady of the adjacent parts, while croup almost 
always attacks children in good health. Again, the cough 
of cedematous laryngitis has not the croupous, brassy sound 
of the cough of croup. In cedematous laryngitis the diffi- 
culty of breathing is greatest in inspiration, while expiration 
is comparatively free, but in croup of any kind inspiration is 
as difficult as expiration. Lastly, cedematous laryngitis has 
no exudation in the pharynx and no expectoration of mem- 
branous shreds as in true croup. 

The sub-glottic variety is distinguished from the supra- 
glottic by the absence of the shrill whistling inspiration so 
marked in cedema of the upper part of the larynx, and on 
examining with the finger the epiglottis and aryteno-epig- 
lottidean folds are normal or nearly so. Sir G. D. Gibb 
points out that the effusion in the sub-glottic variety is "inva- 
riably fibrinous," never serous as in the supra-glottic form, 
and he says that it may be taken as a curious and undisputed 
fact that the sub-glottis, from its anatomical peculiarities, 
secretes fibrin which may be poured out on the surface of the 
membrane or beneath it, according to the special exciting 
circumstances inducing it. It is undoubtedly true that the 
parts below the glottis are less abundantly supplied with 
sub-mucous areolar tissue than the supra-glottic region, and 
also that, as a general rule, the tendency of that part of the 
larynx, when inflamed, is to throw out fibrin, but Burow, 
Rauchfuss and Lefferts. of New York have all reported 
unquestionable cases of sub-glottic cedema in children. 



142 ACUTE (EDEMATOUS LARYNGITIS. 

Mackenzie says that all the examples of subglottic cede ma 
he has met have been of a chronic character, but, curiously 
enough, all the present writer's cases were acute, similating 
membranous croup very closelyindeed. 

CEdematous laryngitis is always a most serious disease, 
even when recognized at its inception. Indeed, the prog- 
nosis is favorable only when the grade of the disease is not 
at all marked and when the inducing cause has ceased to 
progress, or when the oedema affects only one aryteno- 
epiglottidean fold or but one side of the epiglottis. Baehr 
says that "the most common termination is death by 
suffocation, and the prognosis is consequently that of inevi- 
table death ;" von Riemssen teaches that " the higher grades 
of laryngeal stenosis, due to sub-mucous infiltration, usually 
terminate in death if timely interference does not prevent," 
while Prosser James states that " if not relieved it will be 
fatal in a few hours, and cases are recorded in which no 
warning preceded death, which, therefore, may be termed 
sudden." 

Bayle, writing when the mechanism of the morbid process 
was but little known, reports seventeen cases with but a 
single recovery. Sestier compiled statistics of almost all the 
authentic cases on record, and the mortality was 158 in 213 
cases, though the trachea was opened in thirty of the fatal 
cases. In the 55 recoveries, tracheotomy was performed 
twenty times. The primary form of the disease is less 
dangerous than the secondary, and typical oedema — the form 
originating in the larynx itself — is almost invariably fatal. 
"When oedema of the larynx is a primary affection, or is 
connected with acute inflammation of the pharynx or larynx, 
its progress is more rapid, and the chances of a favorable 
termination are also greater, which arises from the affection 
being transient in its nature like the pathological state on 
which it depends" (Trousseau). If the inflammatory action 
should originate in the pharynx, the prognosis is compara- 
tively favorable, but if it commences in the areolar tissue of 
the neck it is almost invariably fatal. Still, one of the worst 



ACUTE (EDEMATOUS LARYNGITIS. 143 

cases the present writer ever saw, commenced in the areolar 
tissue of the neck, and was cured by Sanguinaria, as detailed 
in the remarks on therapeutics. If the 'disease has its 
starting point in syphilis, as is not seldom the case with 
children, the morbid state is generally curable, but if it 
should occur during the course of typhoid fever, the case 
will likely prove fatal. The supra-glottic form is more 
dangerous than the sub-glottic, simply because the parts 
above the glottis are richest in areolar tissue. It is, of course, 
less dangerous in a child of good constitution than in one of 
scrofulous diathesis or in feeble health. Habitual disease of 
the larynx would materially darken the prognosis, and when 
the disease supervenes upon chronic laryngitis, it is almost 
incurable. In the advanced state, when asphyxia has already 
commenced, there can be but little hope, for, even if the 
dyspnoea is relieved, the nervous system may be unable to 
rally from the prostrating influence of the poisoned blood. 

Speaking of laryngitis, Dr. Richard Hughes observes, 
"should oedema glottidis supervene, repeated doses of Apis 
would give the best chance of averting tracheotomy," and 
in his latest work he further says, " It (erysipelatous sore 
throat) is often the beginning of oedema glottidis, in which 
Apis is the great remedy. It has proved curative in more 
than one instance of this affection, where the cause was 
drinking water from a kettle. Such cases are commonly 
fatal." Again, in his excellent Manual of Therapeutics: "I 
think that the best advice I can give you as to the treatment 
of this dangerous condition (oedema glottidis), under what- 
ever circumstances it may occur, is to trust to Apis. Since 
this remedy has cured it even in its most fatal form — -viz., that 
which occurs in children after drinking from the spout of a 
tea-kettle — it will probably be competent to deal with all 
other forms of the malady." Dr. Holcombe observes that 
Apis is especially indicated when the attack has suddenly 
sprung up in the course of an acute disease, in otherwise 
healthy persons, and that it is still more so when it occurs 
n erysipelas, burns, or the eruptive fevers to which the 



144 ACUTE (EDEMATOUS LARYNGITIS. 

bee-virus has more or less affinity. Baehr regards it as one 
of the three remedies which act similarly to the general 
disease— the others being Lachesis and Rhus toxicodendron. 
I look upon Apis as being undoubtedly the first remedy to 
be thought of, though, of course, it does not cover all cases. 
Still, I have succeeded with it when success seemed to be 
unattainable. Holcombe recommends the 3d dilution to be 
used ; I always use the 5th decimal trituration of the sting 
of the bee and the attached sac of the virus, for, as Constan- 
tine Hering remarks, " there is but one right kind," and 
that is it. 

An English physician, Dr. Ainley, of Halifax, communi- 
cates the following excellent case to the Homoeopathic World, 
vol. XIV : 

" In November, 1878, I was summoned at 11 P. M. to see 
a little boy, aged four years, who had been taken ill. The 
history of the case was that he had been all right up to tea- 
time, and, indeed, on being put to bed at 8.30 appeared the 
same, but On being looked at by the parents before they 
retired to rest, as was their custom, they found him breath- 
ing very heavily, and were alarmed and sent for me. When 
I arrived, in a moment I diagnosed " croup " — that is to say 
without asking any questions — and seeing no time was to be 
lost, as the boy's face was already blue and swollen from 
impeded respiration and deficient aeration, I began to 
prescribe my usual remedies, and which I am thankful to say 
usually succeed, viz.: Aconite and Spongia, administered 
every ten minutes in alternation. But as I anxiously watched 
the case, feeling sure a short time would decide for or 
against, I entered into conversation with the parents, and 
began to make fuller inquiries into the previous history of 
the child, and the following little incident was told me, which 
of course turned the whole case : On the same day, at tea- 
time, when the mother had just filled up the teapot with hot 
water, and left it on the edge of the table, the little fellow 
drank out of the teapot-spout, and although it was very hot, 
he seemed to make no complaint of any pain in his throat, 



ACUTE (EDEMATOUS LARYNGITIS. 145 

and played for some time, and even went to bed without 
complaining. Here we had an entirely new condition of 
things, which could have had no true interpretation apart from 
the incident just related ; symptomatically it was a case of 
" Cynanche Trachealis ; " pathologically it was " Cynanche 
Trachealis ;" and I suppose if one had searched through all 
the homoeopathic literature extant only one medicine could 
have been found to have met the case, and that was Apis, 
Apis was promptly given, and in from four to six hours all 
danger might be said to be over." 

Dr. Bruckner, of Basle, publishes an interesting case in 
the A. N. Z., 1873, of which the following epitome is given 
by Raue in the Annual Record for 1874: " A young man, 
who had scarlet fever as a child, suffered from that time from 
an oedematous swelling of some part of his body, regularly 
returning every eight days. For the last three years it threw 
itself sometimes on the glottis, causing fits of suffocation, 
but always terminating in twelve hours. Before the paroxysm 
attacks of bilious vomiting. Relieved, but not cured, by 
Apis 200." , 

In 1869 I wrote: "I have never had an opportunity of 
testing the virtues of Sanguinaria in this disease, but would 
expect considerable from it ;" and in the month of April, 
1874, I had the long-looked for opportunity. On Friday, 
April 17, 1874, I was called to Mrs. C, aged 59, who had 
been complaining for some few days. I found an inflamma- 
tion of the cervical glands of the right side, involving the 
parotid gland to a considerable extent, and accompanied by 
extensive inflammation of the subjacent cellular tissue. The 
parts were hot, tender, swollen and red — in fact, the well- 
known calor, dolor, tumor , rubor — and there was reddening 
of the fauces, with slight pain on deglutition. I prescribed 
Belladonna, 6th decimal trituration, and advised rest, quiet 
and silence. On the following day the situation was but 
little changed, and Mercurius iodatus ruber, 3d decimal 
trituration, was prescribed. 

At 6 o'clock of Sunday morning, April 19th, I received an 



146 ACUTE (EDEMATOUS LARYNGITIS. 

urgent call to the patient, who, I was told, had hardly been 
able to breathe all night. I found her sitting up in bed, 
with a characteristic rasping and sawing sound issuing from 
the larynx, a sound somewhat difficult of description, but 
which once recognized can never be forgotten. The tonsils 
and pharynx were swollen, but auscultation showed that the 
sawing and rasping sound issued from the larynx. The 
cough was dry and harsh, relieved by sitting up in bed, 
aggravated by eating and lying down, and it was accom- 
panied by difficult expectoration of tough and glairy mucus. 
The voice was low and suppressed, and it was with difficulty 
that I could make out the hurried, whispered sentences. 

The pulse was feeble and fluttering, and the lips were 
pale ; but on both cheeks there was a circumscribed redness. 
The pathognomic symptom which made the pathological 
state quite clear to me was the fact that expiration was 
performed more readily than inspiration. M. Thuillier's test 
was decisive as to the diagnosis, for" when the forefinger was 
passed into the larynx, there is a perception of a cushion 
formed by the tumefaction of the sides of the glottis — a soft, 
pulpy body, quite distinct from the ordinary hard feel of the 
parts." 

The diagnosis was acute cedematous laryngitis of the' 
supra-glottic variety — all the more dangerous because it 
was an intercurrent disease — and the peculiar respiration 
arose from the fact that the cedematous membrane which 
filled the glottis closed like a valve against the entrance of 
air, but readily permitted it to pass out. I prescribed 
Sanguinaria 1st decimal trituration, a dose every half hour. 

At 1 P. M. I found that improvement had commenced 
almost as soon as the medicine was given. The sawing and 
rasping sound was now .much diminished, the respiration 
was comparatively easy, inspiration and expiration were 
performed with equal facility, the cough was less frequent 
and less severe, the voice was quite audible, and the patient 
had slept much of the time since morning. The tonsils and 
pharynx were still red and swollen, but the glottis was clear 



ACUTE (EDEMATOUS LARYNGITIS. 1 47 

of the tense and rounded swellings present in the morning. 
The Sanguinaria was continued in the same dose. 

At 7 P. M. I again saw the patient and found that the very 
serious pathological state had almost wholly disappeared. 
The Sanguinaria was continued all night, and in the morning, 
as the acute cedematus laryngitis was no longer present, 
treatment was directed against the inflammation of the 
cervical glands and cellular tissue/' 

" Should Apis fail you, however, you may (before thinking 
of surgical measures) consider the claims of Sanguinaria." 
(Hughes.) 

In 1869 I suggested Aconite as a leading remedy, and, 
although no other writer of our school, save Charles Julius 
Hempel, has endorsed the recommendation, I repeat the 
suggestion with all the more confidence that I have found 
its action prompt and decided in several well-marked cases. 
But it must be given in repeated doses of the mother tinct- 
ure, or 1st decimal dilution. 

Dr. Jacob Reed, Junior, of Philadelphia, reports the 
following case: ''March 16, 1867, evening. Called to see 
Miss B., at 20, who had for some days ' had a bad sore 
throat,' and was reported as choking to death. When seen, 
the patient was evidently suffering from an acute cedematous 
inflammation of the larynx, there being high fever, pain in 
the region of the larynx, difficulty of swallowing and breath- 
ing, voice almost inaudible, every effort at speaking causing 
great pain, inspirations prolonged and stridulous, being 
effected only by violent effort ; there was but little cough ; 
frequent spasmodic exacerbations of these symptoms ren- 
dered suffocation imminent. Ordered inhalations of steam 
medicated with Opium, cold pack to the region of the 
larynx, Aconite and Kali bichromicum ; of the Aconite three 
drops of the tincture of the root were given in a half glass of 
water, of which she took a teaspoonful every twenty minutes. 
This appeared to afford relief, which, however, proved but 
temporary, as upon paying my morning visit, I found the 
patient much worse in every respect, the leaden hue of 



148 ACUTE (EDEMATOUS LARYNGITIS. 

the skin, with the intense anxiety of the countenance, 
showing that she had to fear the result of deficient 
aeration of the blood. This condition of affairs rendering 
tracheotomy necessary, I returned to the office for the 
necessary instruments and assistance, but in the meantime 
ordered two drops of the tincture of the Aconite root to be 
given every ten minutes. Upon returning after the lapse of 
an hour, the patient was so far relieved as to render surgical 
interference unnecessary, and from this the convalescence- 
was steady, although slow and imperfect. There remains, 
after many months, a cough, with hoarseness, owing to 
constitutional tuberculosis." 

According to Bsehr, " we are acquainted with only one 
remedy which has cedema of the glottis among its physio- 
logical effects; that remedy is Iodium." Holcombe, too, 
advises it and I look upon it as being one of our chief 
remedies. In addition to the administration of the remedy 
in the ordinary way, I apply the 1st or 2d decimal dilution 
directly to the cedematous parts. 

Dr. Holcombe says that Arsenicum album is indicated 
when the disease is a genuine anasarca, coming on slowly in 
the chronic diseases of broken down constitutions, especially 
if there is concomitant cardiac or aortic lesion, Bright's 
disease of the kidneys, anaemia or dropsy. Though this 
remedy is also recommended by Raue, I have never seen the 
results that one might expect, even when it seemed well 
indicated. Holcombe recommends it from the 3d to the 
30th dilution. 

Raue and Holcombe both suggest Lachesis, and Baehr 
points out that it specially has the peculiar serous infiltration 
of internal as well as external parts of the body, which sets 
in without any sytnptons that might properly be called 
inflammatory, and which reaches its full development in 
a few hours. I have had no experience with Lachesis. 

Baehr says "Spongia is the principal remedy for the so-called 
catarrhal croup with distinct symptoms of cedema of the 
mucous lining of the glottis," and the same distinguished 



ACUTE CEDEMATOUS LARYNGITIS. 1 49 

writer remarks that another remedy which offers some resem- 
blance is Phosphorus ; in this case, however, the resemblance 
is limited to a single symptom. Holcombe thinks that Chel- 
idonium has " some pathogenetic resemblance to many 
symptoms of this formidable disease," and Rhus toxicoden- 
dron is suggested by Baehr as acting similarly to the general 
disease, but, so far, these recommendations have not been 
acted on. Raue thinks that China and Stramonium are, 
perhaps, the most important remedies, and that the first- 
named remedy would be of special value when the oedema 
is a so-called pure dropsy ; and he further suggests Arum 
triphyllum, of which I have had no experience. 

But let us suppose that in a case of undoubted cedematous 
laryngitis, the patient gets rapidly worse in spite of the best 
selected remedies, or that the disease was far advanced 
before medical assistance was called. What will the physi- 
cian do in either of these contingencies? Will he permit his 
patient to die, or will he make an effort to remove the 
mechanical obstacle which impedes respiration ? It appears 
to me that no conscientious physician of our school could 
possibly ignore surgical procedures, even if they had not 
been advised by Hughes and Hartlaub. Baehr, too, says 
that " since in this disease we cannot fall back upon experi 
ence for a positive knowledge of the curative action of drugs, 
it would be criminally indiscreet to depend exclusively upon 
internal treatment." Holcombe, of New Orleans, teaches 
that scarification of the infiltrated tissues is of immense 
benefit when it can be thoroughly done, and he adds that 
" tracheotomy is the last, but frequently imperative resort." 
The surgical procedures are two in number — scarification 
and tracheotomy — the former of use in the supra-glottic 
form, the latter in the sub-glottic variety. To M. Lisfranc 
is due the credit of introducing scarification ; Dr. G. Buck, 
of New York, revived the operation, and it has been still 
further improved by Sir George Duncan Gibb. It is recom- 
mended by all the best authors, Sestier, Valleix, von 
Riemssen, though Mackenzie says doubtfully that " scarifi- 



150 ACUTE ^EDEMATOUS LARYNGITIS. 

cation is often successful when the disease is circumscribed." 
In some few cases the laryngeal mirror may be employed, 
but in most cases the practitioner must be guided by the 
sensation of the ringer. Mackenzie's laryngeal lancet is 
decidedly the best and safest instrument, though Buck's 
laryngeal knife is little inferior, and a common bistoury, 
wrapped with sticking-plaster almost to the point, is a good 
instrument in good hands. The older surgeons advised 
numerous small incisions, but von Reimssen recommends the 
operator to make several long incisions, whereupon the 
swelling generally collapses at once. Trousseau confesses 
that he has not had the courage to practice this operation 
and he considers that Buck has exaggerated both its utility 
and facility. Legroux recommended that the cedematous 
swelling be lacerated by the nail of the index-finger cut to a 
sharp point, but it is doubtful if the advice has ever been 
acted on. After the operation, warm gargles or the inhala- 
tion of the steam of hot water will encourage the evacuation 
of serum. Sir G. D. Gibb recommends the introduction of a 
suitably curved bougie, half an inch in diameter, into the 
larynx, for the purpose of squeezing out the serum through 
the punctures made by scarification, but, though this would 
be easy in adults, it would be difficult in children. 

We have a great consensus of the authorities as to the 
value of tracheotomy in this disease, and here the homoeo- 
pathic writers, Bsehr and Holcombe, are one with Trousseau, 
von Riemssen and Mackenzie, all the great lights of the 
other school of thought. Baehr says that in this disease, 
much sooner than in croup, success may be expected from 
tracheotomy, for the reason that the trachea is not usually 
involved, while von Riemssen urges that we must bear in 
mind, as a general rule, that in severe cases the danger to the 
life of the patient, if the physician maintains an expectant 
attitude, as uncommonly great, and that even postponing 
tracheotomy for a few hours may be destructive of the 
patient, if the physician leaves him in the meantime, and he 
further points out that there is no estimating the rapidity 



ACUTE (EDEMATOUS LARYNGITIS. 15I 

with which stenosis of the glottis may advance. "We 
should make it a ride, under no circumstances to leave a 
patient with laryngeal cedema, and, if the instruments are 
not at hand in time, to perform tracheotomy with a penknife 
rather than let the patient suffocate. This was done by a 
physician with whom I am acquainted, who on making a 
journey across country on the island of Riigen, and, being 
called into a farm-house to see a patient with cedema of the 
glottis, found himself without even a pocket-case. The 
instance which Stannus J. Hughes narrates is also a very 
pretty illustration of this. A student of medicine saved a 
man, who was at the point of suffocation from oedema of the 
glottis, by cutting through the crico-thyroid membrane with 
his penknife, and introducing the tube of his penholder as a 
canula (von Riemssen). 

But tracheotomy should not be delayed till the patient is 
all but moribund, and it should be persisted in, as Durham 
points out, even though the difficulties attending the opera- 
tion are great and the chances of a successful result appear 
small. If the suffocative paroxysms are severe, if they 
follow each other rapidly, if the difficulty of breathing in 
the intervals of the seizures is considerable, then the opera- 
tion should be performed at once, especially if the slightest 
signs of poisoning by carbonic acid manifest themselves. It 
is in the child a comparatively simple operation, and, while 
it may be the means of saving life, it never can be the cause 
of death. Professor Wood remarks that well-authenticated 
cases are. on record, in which patients have been restored 
after respiration had ceased, and the pulse could be no longer 
felt at the wrist. One would think that chloroform would 
be exceedingly unsafe, but experience proves that it is not 
so, and it would be almost impossible to operate on young 
children without it. The patient should be placed on a 
lounge with a cushion behind the neck and shoulders, so that 
the head is thrown back and the trachea is well forward. 
With lamp-black or a piece of charcoal the operator should 
trace on the skin the outline of the incision he proposes to 



152 ACUTE (EDEMATOUS LARYNGITIS. 

make. The skin is then raised and cut through, next the 
muscles are carefully incised and retracted with a hook on 
each side. The wound should be sponged before each cut 
with the bistoury, and all haemorrhage should be arrested 
before the trachea is opened. When the white rings of the 
trachea are exposed, a small puncture should be made in 
them, which should be enlarged with a probe-pointed 
bistoury till the orifice is say three-quarters of an inch in 
length, and it is important to note that the trachea must be 
cut exactly in the middle line. A double canula should then 
be placed in the wound by means of a dilator, and the canula 
should be secured by means of tapes fastened behind the 
neck. B^etonneau lays down the practical rule that the 
canula should always be at least of the diameter of the 
glottis of the subject. After the operation, the patient 
should be enveloped in a warm and moist atmosphere, but, 
at the same time, ventilation must be maintained. Then, 
well-selected remedies should be administered with the view 
of acting on the cedematous parts. For fuller particulars on 
tracheotomy, I would refer the reader to the very able article 
on that subject by Arthur E. Durham, Assistant Surgeon to 
Guy's Hospital, in Holmes' System of Surgery, or the article 
in the Internation Encyclopaedia of Surgery. 

Mackenzie says that ice should be " uninterruptedly swal- 
lowed," and Holcombe has found it beneficial ; von Niemeyer 
relates that under this treatment he once witnessed the 
recovery of one of his colleagues, in whom suffocation 
seemed so imminent that the medical attendants hardly 
dared to defer tracheotomy. 

Aphorisms. 

i. Acute cedematous laryngitis is not common in children, 
simply because in children the larynx is scantily supplied 
with sub-mucous areolar tissue. 

2. The older writers held that this disease was non-inflam- 
matory, but later observers have conclusively shown that 



ACUTE (EDEMATOUS LARYNGITIS. 1 53 

inflammatory oedema of the larynx is much more frequent 
than non-inflammatory infiltration. 

3. Acute cedematous laryngitis is very like croup, but in 
the first-named disease dyspnoea is greatest on inspiration, 
while expiration is comparatively free, but in all the croups, 
inspiration is as difficult as expiration. 

4. Formerly it was believed that the effusion of sub-glottic 
cedematous laryngitis was invariably fibrinous, but it is now 
quite certain that it is often serous. ' 

5. Acute cedematous laryngitis is a very fatal disease, 
Sestier reporting 158 deaths in 213 cases, though trache- 
otomy was performed in 30 of the fatal cases. 

6. Acute cedematous laryngitis originating in the larynx 
itself is almost invariably fatal. 

7. The leading homoeopathic remedies are Apis mellifica, 
Sanguinaria, Aconite, Iodium, Arsenicum album, Lachesis 
and Spongia. Minor remedies are Phosphorus, China and 
Rhus toxicodendron. 

8. As a last resort, scarification is of great value in the 
supra-glottic variety, and tracheotomy in both supra-glottic 
and sub-glottic forms of the disease. 

9. Durham urges that tracheotomy should be persisted in, 
even though the difficulties attending the operation are 
great, and the chances of a successfnl issue appear small. 

10. Mackenzie, Holcombe and von Niemeyer all strongly 
advise the uninterrupted swallowing of small pills of ice. 



CHAPTER VII. 



Spasmodic Croup. 



Croup is one of the «most dreaded of infantile diseases, 
and it is also one of the least understood. There are two 
varieties of croup proper, the spasmodic and the pseudo- 
membranous, the first a severe but comparatively inocuous 
disease, the second apparently less severe but in reality one 
of the most terrible of maladies. But it must be distinctly 
understood that while distinct types of these maladies exist, 
that frequently they shade off and run into each other in 
such a manner that even the most experienced physicians 
are, at times, perplexed. A case will commence as spasmodic 
croup and apparently be progressing finely, when the dreaded 
pseudo-membranous complication makes its appearance, and 
soon the patient is hopeless. Or a child will have repeated 
attacks of spasmodic croup, recovering from each attack 
after a good deal of suffering; long success lulls the watch- 
fulness of the mother, and at length an attack assumes the 
pseudo-membranous form, and being met by unsuitable 
treatment, it soon proves fatal. The name of croup conveys 
very different ideas to different minds, and a case which one 
physician dignifies with that title appears to another 
altogether beneath his notice. Many years ago I was visiting 
a physician, and as we sat gossiping in his office, he suddenly 
remarked that he must go and see a case of croup. Having 
been accustomed to see severe forms of the disease, I started 
up, seized my hat, and made ready for a rapid march. My 
friend remarked that there was no need of haste, and so, 
after a very leisurely walk, we came to the house. Ushered 
into the parlor, we found a couple of ladies sewing and 
chatting, and two or three children playing on the floor, but, 



SPASMODIC CROUP. 155 

to me, no signs of a croup patient. My friend, however, 
called a little child from its play and auscultated its larynx 
carefully, requesting me to do the same. I olid so, and after 
a careful examination I found that the child had a very 
slight cooing in the larynx, but no cough, no hoarseness, no 
fever, no croup. 

Like some other infantile diseases, spasmodic croup has 
been burdened with a multiplicity of names. It has been 
called false croup and pseudo-croup in contradistinction to 
true croup, commonly called pseudo-membranous croup. 
Guersant calls it stridulous laryngitis ; Bretonneau names it 
stridulous angina ; while Millar and Simpson speak of it as 
the acute asthma of infants. Cullen's name, " cynanche 
trachealis," is wholly wrong, as it directly leads to erroneous 
ideas as to the site of the disease, and Morell Mackenzie, the 
latest writer on laryngeal diseases, gives spasmodic croup as 
one of the synonyms of spasm of the glottis. The French 
writers, Rilliet and Barthez, and the American writers, Meigs 
and Pepper, concur in calling it spasmodic laryngitis, while 
Professor Wood calls it catarrhal croup, Wichmann, Michaelis 
and Double style it spasmodic croup, and I prefer that name, 
as it appears to me that the laryngeal spasm is the essential 
feature of the -disease, while the catarrhal symptoms are less 
characteristic ; but it is well to bear in mind the fact that 
severe catarrhal or even frankly inflammatory symptoms may 
arise in the course of the disease, calling for modifications in 
treatment. 

Spasmodic croup, then, may be defined to be a laryngeal 
disease almost peculiar to infancy, consisting of a violent 
spasm of the interior muscles of the larynx, combined with 
a catarrhal inflammation of the adjacent mucous membrane, 
but without pseudo membranous exudation; this combina- 
tion of laryngeal spasm with catarrhal inflammation causing 
important changes in the respiration and in the voice. 
There are thus several elements in the disease, for the 
nervous system is involved as well as the vascular, so that 
spasmodic croup is allied to the neuroses as well as to the 



156 SPASMODIC CROUP. 

inflammations. At times the catarrhal inflammation is quite 
trifling, while the spasmodic action is distinctly marked, or 
the inflammatory action may be very severe, with very little 
laryngeal spasm, in which case the disease would approxi- 
mate to catarrhal laryngitis. " The spasm of the laryngeal 
sphincter seems to be the result of a disordered action of the 
excito-motor innervation of the part, the irritant, which is 
productive of the morbid innervation, being, in all proba- 
bility, the inflammation of the laryngeal mucous membrane, 
which, as has been already stated, constitutes one element of 
the malady. The nervous element predominates in the 
early part of the attack, but towards the conclusion the 
spasmodic symptoms disappear entirely, and we have left 
only those which depend on the local tissue changes." 
(Meigs and Pepper.) Dr. Copland writes : " The experi- 
ments of Schwilgue, Jurine, Albers, Schmidt and Chaussier, 
as well as pathological observation, prove that the form of 
disease called false croup by the above authors pro- 
ceeds from a similar state of morbid action as that 
denominated the pure disease (pseudo membranous croup), 
and is merely a modification resulting from less intensity of 
the inflammation, peculiarity of the temperament and habit 
of body, the causes occasioning it, and the greater predomi- 
nance of the spasmodic or nervous states." This is decidedly 
erroneous, for spasmodic croup differs radically from 
pseudo-membranous croup, and I hold with Meigs and 
Pepper that they are distinct affections, which may, in the 
great majority of cases, be distinguished from each other at 
a very early stage by a casual observer. I concede, of course, 
that pseudo-membranous croup may be developed in the 
course of spasmodic croup, and the practical physician must 
never forget the pregnant words of Rindfleisch, " the devel- 
opment of a false membrane is connected in the closest man- 
ner with the catarrhal state, and constitutes an anatomical 
acme of the morbid process!' At one end of the scale you 
have a mild form of the disease, differing from catarrhal 
laryngitis only in the presence of a slight degree of laryngeal 



SPASMODIC CROUP. 157 

spasm ; at the other end you have a severe type resembling 
pseudo-membranous croup so closely as to try the acumen 
of the keenest observer. Yet the distinction between the 
worst case of spasmodic croup and even the very mildest 
case of pseudo-membranous croup is of vast moment to the 
patient, since the prognosis is so widely different in these 
two diseases. 

Spasmodic croup appears to be more frequent on this 
continent than the pseudo membranous variety, while the 
contrary seems to be the case in Europe. For one case of 
the pseudo-membranous we meet with at least ten of the 
spasmodic ; hence, while with us in all varieties of croup 
massed together the mortality is comparatively small, 
European writers state that almost one-half of those attacked 
die. Spasmodic croup, again, is, generally speaking, a 
disease of infancy and early childhood, while pseudo-mem- 
branous croup often attacks those of maturer years. 

In common with the more dangerous form of croup, 
spasmodic croup affects male children more frequently than 
female, even when the same care is taken of the patients, a 
circumstance of which no adequate explanation has yet been 
given. Out of a hundred cases, sixty will occur in boys and 
forty in girls, and this observation has been repeatedly con- 
firmed. It is most frequent in fall and winter, and also in 
spring when winter is breaking up, and it is rarely seen in 
summer. As a general rule spasmodic croup is prone to 
appear on the banks of lakes and in the vicinity of large 
bodies of water. 

Spasmodic croup is essentially a disease of infancy and 
childhood. Guersant says that it occurs most frequently 
between the ages of two and seven ; J. Lewis Smith thinks 
that it ordinarily occurs between the ages of two and five ; 
Condie has met with it in children of nine or ten months, 
but less frequently than in those between two and eight 
years. Meigs and Pepper state that " it occurs most 
frequently during the period of the first dentition, being 
more common in the second year of life, which is the time 



158 SPASMODIC CROUP. 

of the greatest activity of the first dentition, than at any 
other age, though it is often met with in the third and fourth 
years." Rilliet and Barthez are of opinion that it is most 
common between the ages of three and five, thus omitting 
the very year, the second, in which it is most frequently 
seen. A few of my cases, not more than eight or ten per 
cent, of the whole number, occurred during the first year of 
life ; at least a third of the whole number were in the second 
year; and a somewhat smaller proportion, say one-fifth, were 
in the third year, after which they decreased, till in the 
seventh and eighth years very few cases were seen. 

Spasmodic croup is a sporadic disease, in which respect it 
differs from pseudo-membranous croup, which is occasionally 
epidemic. Rilliet and Barthez, however, state that " it is 
incontestable that it may prevail epidemically," but this 
opinion is based not on their own observations, but on those 
of Jurine, of Geneva, who describes an epidemic which 
raged in that city in 1808. My own opinion is that the 
so-called epidemics of this disease depend upon certain 
conditions of the atmosphere exciting the morbid state to 
an unusual degree, and that it is never epidemic like whooping 
cough or even pseudo-membranous croup. Again, the disease 
is hereditary in certain families, and almost every physician 
of experience can call to mind families in which it has 
prevailed generation after generation. Dr. J. F. Meigs, of 
Philadelphia, remarks, " I am acquainted with one family in 
this city in which the children for three generations were 
extremely liable to it; with another, in which the grand- 
mother and grand-children were frequently attacked ; and 
with a third in which the father and children showed the 
same predisposition in the most marked manner." 

This disease occurs alike in the robust and in the weak, 
and many children are predisposed to it when laboring under 
any digestive derangement. The most important exciting 
cause is exposure to cold, either sudden transitions from 
heat to cold or exposure in the open air. Narrowness of the 
rima glottidis is at times a predisposing cause, and nervous 



SPASMODIC CROUP. 1 59 

children are at all times most likely to be attacked. Dr. J. 
Lewis Smith has observed that this disease is not uncommon 
at the commencement of measles, and Dr. Condie notes that 
after an attack has once happened, the occurrence of any 
sudden or violent mental emotion is liable to excite a 
paroxysm. 

It is characteristic of spasmodic croup to attack suddenly 
and without warning ; as old Dr. Meigs quaintly puts it, 
" there is often not the least reason to suppose the child sick 
until the moment of explosion of the attack, an attack which 
in many examples is more violent in the first moment of its 
existence than in any subsquent time." In a considerable 
number of cases the attack is preceded by a paroxysm of 
teething fever, and so close is the connection between the 
fever of dentition and spasmodic croup that Dr. Copland 
affirms, " I have scarcely ever seen a well-defined case uncon- 
nected with dentition." In a much larger number of cases 
there is slight coryza with hoarse cough. Now, hoarseness 
excites little attention in adults, as in acute cases is does not 
usually indicate any special degree of danger, yet the 
contrary is the case with children, as with them hoarseness 
always indicates danger, and it should never be neglected. 
The first paroxysm generally takes place in the night during 
the first sleep, between ten o'clock and midnight. Out of a 
hundred cases ninety-five will occur in the night, and the 
remaining five in the afternoon, and three-fourths of the 
night cases will take place before midnight, and the 
remaining fourth after that hour. With or without, then, 
any premonitory symptoms, the child is attacked by a dry, 
ringing clangorous cough, which has been compared to the 
notes of a trumpet mingled with the rasping of a large saw, 
but which, as Professor Wood remarks, " is, in fact, compar- 
able to nothing else in nature, and to be appreciated only by 
being heard." This sonorous and barking cough is accom- 
panied by prolonged inspiration, by a shrill and rasping 
sound, and by rapid and irregular respiration. At times the 
breathing is so very irregular that suffocation appears to be 



160 SPASMODIC CROUP. 

impending, and the child tosses about in its bed as if fighting 
for air. The characteristic cough is, according to Wood, 
occasioned, in all probability, by a certain spasmodic rigidity 
of the vocal cords, giving an almost metallic tension to the 
sides of the rima glottidis. The voice is hoarse and rough, 
though rarely suppressed, and then only for a brief period — 
this is one of the most salient points of difference between 
the disease under consideration and pseudo-membranous 
croup. There is but little real pain in the larynx or trachea, 
but a feeling of constriction which seems to be still less 
endurable than pain. The little patient may endure the 
attack for a little time with considerable fortitude, but soon 
he sits up in bed gasping for breath, or lies on his back with 
his neck stretched to the utmost, while the # throat is grasped 
by the hands as if to remove some obstacle to respiration. 
If able to speak, he complains- of pain and tightness at the 
throat, while the face has an anxious and troubled expres- 
sion. He becomes greatly agitated, cries violently between 
the fits of coughing, and begs piteously for help. When the 
paroxysm first comes on the face is flushed, the skin warm, 
and the pulse strong and frequent, but as the attack becomes 
more intense the face becomes of a livid hue, while the 
extremities are cool and the pulse frequent, feeble and 
fluttering. Copland says that " there is little or no increase 
of animal heat or fever," but fever was present in the vast 
majority of my cases, and there is a striking consensus of 
opinion on this point. After lasting from twenty minutes to 
an hour, or even two hours or more, the breathing becomes 
easier, the cough less frequent and less clangorous, and the 
sawing sound is only heard when the little patient cries. 
Often as soon as relief is obtained, the child falls into a 
sweet sleep. In the morning he seems nearly well, having 
only an occasional croupy cough, with hoarseness of the voice 
and redness of the fauces. At times this croupous cough 
continues for several days, gradually getting milder and less 
frequent, till at last it ceases entirely. When the attack 
occurs 'early in the night, it is likely to be followed by a 



SPASMODIC CROUP. 16l 

second milder attack towards morning ; as the second evening 
approaches, the patient is the subject of a similar paroxysm 
of varying severity. Professor Wood says that the symp- 
toms are often more violent than at first ; Dr. J. F. Meigs 
says that, as a general rule, the first attack is the most severe. 
So far as my observation extends, I have noted that while 
the paroxysm is more prolonged and more exhausting, the 
symptoms appear to be less severe. 

This may be taken as a fair account of a case of moderate 
severity, but at times the laryngeal inflammation is more 
intense and apparently involves a larger extent of the mucous 
membrane. The cough is hoarser and more frequent, the 
respiration more difficult, the fever more pronounced, and 
this state is developed, as a general rule, earlier in the night 
than the milder form of the disease. As the night advances 
all the symptoms intensify, till actual suffocation is threat- 
ened. Towards morning amelioration takes place, the fever 
declines, the breathing becomes easier, the cough looser, the 
stridulous sound less marked. But as the next evening 
approaches, all the symptoms reappear, to be followed by 
another remission during the day, which, in its turn, is 
followed by another night attack, and so on, for several days. 
I have attended a number of cases in which the daily remis- 
sion hardly existed, for the disease continued day and night, 
for three or four days. If no fortunate change is brought 
about by treatment, the breathing becomes more and more 
difficult, the cough rarer and more feeble, and is finally sup- 
pressed altogether, the voice, is hardly audible, the pulse is 
small and rapid, the face pale and cool, with pinched and 
contrasted features. Finally the child becomes comatose, 
and death takes place from asphyxia, often with general 
convulsions. In favorable cases the fever declines, the 
voice becomes stronger, the cough looser, the stridor dimin- 
ishes, and the patient rapidly enters on convalescence. 
These severe cases last longer than those of the milder type. 
A severe case will keep the patient in real danger for two, 
three, or even four days, while the milder cases subside after 



1 62 SPASMODIC CROUP. 

forty-eight hours, the patient rarely being in real danger. 
In severe cases the disease is often followed by hoarse cough 
with husky breathing, and this state is sometimes difficult of 
cure. The disease is very likely to return, and paroxysms 
more frequently come on at intervals of from six to twelve 
months than in a shorter period, though I have attended 
patients who have had five or six attacks in a year. 

Auscultation of the larynx should never be neglected, and 
for this purpose I now prefer the single stethoscope to the 
double one. On auscultation it will be found that the 
respiration is dry and wheezing, with a hissing, sonorous 
sound, as if the larynx were narrower than usual, and had 
rigid and unyielding walls. It is well to bear in mind the 
remark of M. Trousseau, that the hoarse-sounding, croupal 
cough is not a sign of exudation in the larynx, but rather of 
its absence. 

Spasmodic croup is rarely fatal, so that we are not so 
conversant with its morbid anatomy as we are with that of 
the more formidable pseudo-membranous croup, and many of 
the post-mortem changes are wholly inadequate to account 
for the fatal result. The pathological state present is slight 
inflammatory hyperaemia, with perhaps increased activity Of 
the mucous follicles. Very severe cases have redness of the 
larynx, extending to the trachea, or even to the bronchi, and 
this redness may either be continuous or in patches. There 
is usually a slight swelling of the sub-mucous tissue, with 
viscid and adherent mucus if death has taken place at an 
early stage of the disease, or with more abundant and puru- 
lent mucus if the disease proved fatal at a later period. 
Many have supposed that death often takes place from a 
literal occlusion of the larynx, but this is very seldom the 
case, for, in a vast majority of cases the larynx is sufficiently 
open for the purpose of respiration, and we conclude that 
many patients are asphyxiated by spasmodic contraction of 
the laryngeal muscles. " In some rare instances, no signs of 
disease are discovered in the mucous membrane, and the 
patient has probably died of spasm, consequent upon high 



SPASMODIC CROUP. 1 63 

vascular irritation or congestion, the marks of which disap- 
pear with life." (Wood.) 

Almost the only disease with which spasmodic croup is 
likely to be confounded is pseudo-membranous croup, and 
the diagnosis will be carefully considered in the next chapter. 
It may also be mistaken for spasm of the glottis ; the diag- 
nosis will be found in the chapter on that disease. 

Spasmodic croup is very rarely a fatal disease under 
homoeopathic treatment. Still, cases which have been badly 
managed under other practitioners, may die under the care 
of an homoeopathic physician ; and the worst kind of misman- 
agement consists in the administration of violent emetics 
for the purpose of "clearing out the phlegm and breaking 
up the spasm," according to the wont of our allopathic 
step-brethren. I am satisfied that the irritant action of 
these emetics is one of the principal means whereby mild 
cases of croup are converted into severe ones. Very shrewd 
is the remark of Dr. J. Lewis Smith, "While a favorable 
opinion in reference to the result may ordinarily be expressed, 
the physician should not forget the fact that death may 
occur." One would say that a certain amount of danger is 
present when the disease lasts longer than forty-eight hours, 
and that the danger increases with the prolongation of the 
disease. When the paroxysms diminish in intensity, when the 
fever declines and the cough becomes moist, a favorable termi 
nation may confidently be expected. On the other hand, 
an extremely small and rapid pulse is an unfavorable sign, 
especially when met with in conjunction with coolness of the 
extremities; a marked intensity of the stridulous sound, 
especially in the expiration ; suppression of the voice and 
extreme dyspnoea; paleness of the face and diminution of 
strength would form an extremely ominous group of symp- 
toms. Should convulsions supervene in addition, there 
would remain no ground for hope. 

Dr. Duncan, of Chicago, accurately remarks that "the 
treatment of spasmodic croup has been so mixed up with 
that of membranous croup and laryngitis (simplex) that the 



I64 SPASMODIC CROUP. 

literature is very unsatisfactory," and he correctly adds, " the 
advice of Benninghausen to give Aconite, Spongia and Hepar 
is about as good as any routine treatment." Aconite is one 
of the leading remedies in the treatment of both spasmodic 
and pseudo-membranous croup, though Dr. Alphonse Teste 
says that it " is indicated in croup in the rare cases of violent 
fever in the beginning ; from the moment that the febrile 
symptoms diminish a little, or when, after one or two doses, 
it seems to produce no effect, it should be discontinued, and 
that finally, under penalty of losing precious time, when 
often the minutes are to be counted." On the other hand, 
Croseric says " the first medicine to employ when the croup 
declares itself is Aconite," and Duncan remarks that "Aconite 
is often the only remedy needed, as it corresponds to the 
spasm, the restlessness, the anxiety and the fever that arises." 
Aconite is indicated when the patient is attacked in the 
evening after sleeping, though he has been restless and 
feverish before going to bed. The patient has great nervous 
and vascular excitement, with restless tossing about in the 
bed. On attempting to swallow he complains of pain in the 
throat, and this is aggravated during deglutition, though it 
is never really absent. The cough is dry, hacking and 
frequent, and it follows every expiratory effort, but is absent 
during inspiration. Sometimes the patient wants to cough, 
but restrains himself on account of the pain. The cough, 
as well as the stridulous sound, is distinctly paroxysmal, and 
it is characteristic that these are heard only during inspira- 
tion. The pulse is accelerated, the skin dry and hot, and the 
patient drinks with avidity. u The children attacked with 
this form of croup are the nervo-sanguine or nervo-bilious, 
i. e., the nervous active, while membranous croup attacks 
lymphatic children as a rule. The more nervous the child 
the longer the spasm continues " (Duncan). In mild cases 
the dilutions will suffice, but when the case is threatening I 
put two or three drops of the tincture of the root in a 
tumbler of water, and give a teaspoonful every half hour, or 
even every fifteen minutes. 



SPASMODIC CROUP. 1 65 

By almost universal consent Spongia occupies the next 
place to Aconite in the treatment of croup. Dr. Hughes 
says that "the two leading remedies in croup are Aconite 
and Spongia." while Professor Hempel says still more em- 
phatically that " in this disease we have found that if 
Aconite and Spongia leav^e us in the lurch, the chances of 
recovery are very slight indeed." On the other hand, Dr. 
Teste says, " The good effects of Spongia are incontestable, 
bnt they have been exaggerated; Spongia belongs to the first 
period. I do not use it.'' Hahnemann says of Spongia: 
" Its most remarkable therapeutic virtue is to cure croup ; 
among other symptoms it is indicated in this disease by 
difficulty in breathing, as though a plug had lodged in the 
throat, and as though the larynx were so constricted that 
breath cannot pass through it." Hempel recommends it to 
be given if Aconite produces a profuse, warm perspiration, 
and the spasmodic breathing still continues. In the croup 
of Spongia the larynx is painful, as if pressed, with a burn- 
ing and constrictive sensation in the organ ; respiration is 
difficult, as if a plug were in the throat ; it is wheezing, 
hissing and sawing, and at intervals there are suffocative fits, 
during which the child is unable to breathe except with the 
head bent backwards ; the cough is hollow and barking, with 
difficult expectoration of scanty mucus ; coughing causes pain 
in the trachea and lungs. Dr. Paine, of Bath, Maine, 
observes : " It seems that Spongia nearly covers the same 
symptoms as Aconite, with this difference and addition : in 
Spongia croup the stridulous respiratory sound is always 
during inspiration and the cough less constant, and excited 
only by the inspiratory act ; and the cough and sibilant 
respiratory sound are not so constantly concurrent as the 
Aconite croup. There is also, in Spongia croup, fluent 
coryza, and sometimes sneezing, with saliva dribbling from 
the mouth, which we do not see in Aconite croup." I 
remember hearing Dr. Constantine Hering remark that 
Spongia has aggravation in the evening, while Hepar has 
aggravation in the morning. The cough of Spongia is piping, 



l66 SPASMODIC CROUP. 

crowing, and of a very dry sound, with rough, crowing cry, 
and sensitiveness to the touch ; while the cough of Hepar is 
deep, rough and barking ; hoarseness or aphonia, with slight 
suffocative spasms ; respiration not without rattling of 
mucus. The cough of Spongia is worse when sitting erect and 
better in the horizontal position, while the cough of Hepar 
is excited by lying and is aggravated by lying with the head 
low, and is better with the head high. The cough of Spon- 
gia is improved by eating and drinking, while the cough of 
Hepar is excited by cold diet. Hempel recommends the 
use of the tincture. I have always used the 2d or 3d deci- 
mal dilutions, prepared and administered in the same manner 
as Aconite. 

In routine practice — and some of Hahnemann's followers 
adhere to routine as abjectly as did the Esculapians whom 
Hahnemann scourged — it is customary to give first Aconite, 
then Spongia ; next, " if that don't do," Hepar. Even 
Hartmann, who is not usually a routinier, recommends 
Spongia to be given after Aconite, adding, "in twenty-four 
hours the danger is generally over. If, after this lapse of 
time, the cough should still have the peculiar croup sound, 
the breathing should still be hissing, or if there should still 
be danger of suffocation, Hepar is then to be employed.'' 
The dry, harsh, deep and hollow cough of Hepar is appar- 
ently caused by tickling in the larynx or scraping in the 
trachea, and is increased unto vomiting by a deep inspira- 
tion ; there is a constant mucous rattling from which the 
patient vainly endeavors to obtain relief by expectoration ; 
there is pressing in the throat, with a constrictive feeling as 
if he would be suffocated. The respiration is exceedingly 
quick and laborious, and the voice is hoarse and weak. The 
skin is dry and burning, and the patient is restless and 
inclined to weep. Dr. Hughes does not assign Hepar a 
prominent place in the treatment of croup, merely stating 
that it is useful in restoring the laryngeal membrane to its 
normal condition when the croup is hoarsely mucous ; and 
Dr. Duncan considers that the remedy is indicated "after the 






SPASMODIC CROUP. 1 67 

spasm is relieved, and there is a loose, hoarse cough, worse 
towards evening, with a little fever, due to the obstruction 
of the mucus." Dr. Edmonds gives this remedy " for the 
remnant of symptomatic debi'is that may be found on hand 
towards the conclusion of the case, mainly in the shape of a 
cough, which seems rather irritative than inflammatory:" 
Dissolve a grain of the 4th or 5th decimal trituration in half 
a tumblerful of water, and give a teaspoonful every half hour 
or oftener. 

Phosphorus is one of the remedies rarely given at first, but 
held in reserve, as it were, in case the other remedies should 
fail. Kreussler says, " If these three remedies (Aconite, 
Spongia and Hepar) should remain ineffectual, or should 
only effect a partial cure, Phosphorus is still left us." In 
like manner, Laurie advises Phosphorus " in cases where 
Hepar may fail to remove the symptoms we have enumerated 
under that remedy ; or where Aconite and Spongia, as well as 
Hepar have been merely productive of temporary benefit." 
The cough of Phosphorus is dry and tickling, but not very 
harsh sounding, with hoarseness and pain in the chest as if 
excoriated, and a continual irritation in the larynx and 
trachea, with shortness of breath ; or expectoration of 
mucus, with hollow cough. Phosphorus closely resembles 
Hepar, but it differs materially from Spongia. In Phosphorus 
the voice is trembling and hissing, while in Spongia the 
voice is interrupted. The respiration of Phosphorus is 
generally quick, while in Spongia it is predominantly slow. 
In Phosphorus the expectoration is most constant morning 
and during the day, while in Spongia the cough is generally 
dry ; expectoration not constant ; is loosened in the morning 
and swallowed. Riickert remarks that Phosphorus is some- 
times given with benefit when the improvement seemed to 
stop ; it did not, however, accelerate the cure. 

Hartmann recommends it for obstinate hoarseness with 
slight catarrhal croup remaining after the disease is cured, 
and he also gives it for the tendency to relapse. Some 
twenty years ago I attended a case of croup, and the child 



l68 SPASMODIC CROUP. 

got well, except a hoarseness which remained and excited my 
suspicion. But the parents insisted that the child was doing 
well. Next day another attack of croup destroyed the 
child's life. Since then I have never failed to use the Phos- 
phorus under similar circumstances." I have found Phos- 
phorus of great use for the weakness remaining after the 
attack, and when given at long intervals, and in the 12th to 
the 30th dilution, it often removes the predisposition to the 
disease. Of late years, I have found Sanguinaria still more 
effective for the same purpose. In acute cases I use the 5th 
or 6th decimal dilutions, but the removal of the predispo- 
sition requires higher potencies. 

Our practitioners may thank Dr. Duncan, of Chicago, for 
recalling their attention to Lobelia inflata as a remedy for 
spasmodic croup, a remedy which had almost passed out of 
our minds, but which has done excellent service in the past. 
" Lobelia cases resemble those of Aconite with this differ- 
ence : there is more dyspnoea and the spasm affects the 
oesophageal muscles, impeding deglutition as well as respira- 
tion. Older children will describe a sensation of a lump in 
the throat (fgn), but the constant ringing cough, stridulous 
breathing, and great anguish and fear of suffocation, distin- 
guish the case from Ignatia or Aconite" (Duncan). 

In pressing cases it would be well to consult the thera- 
peutics of pseudo-membranous croup in the next chapter, 
especially the remarks on Sanguinaria, which for many years 
has been my sheet-anchor in both forms of croup. 

The little patient should be kept as tranquil as possible, 
and this is just as necessary during the interval as it is during 
the attack. The atmosphere of the sick-room should be 
pure and of equable temperature, but draughts should be 
carefully avoided ; I have known a number of serious relapses 
from neglect of this self-evident precaution. I have seen 
decided benefit from charging the atmosphere of the room 
with the vapor of warm water. The dress worn during the 
illness should be loose and easy, and a woollen wrapper 
should be worn in addition to the usual night-dress. If 



SPASMODIC CROUP. I69 

possible, the child should be kept in bed during the entire 
time of the acute attack, but a patient would be safer up 
and dressed than sometimes in bed and sometimes out of it 
— all in the night-dress. Condie attaches a good deal of 
importance to supporting the child in an erect posture 
during the paroxysms, and I have found that respiration is 
much easier when this simple recommendation is followed. 

Almost all medical writers recommend a warm bath, say 
of the temperature of ioo°, as soon as possible after the 
commencement of the attack, with the view of relieving the 
spasmodic action of the laryngeal muscles. I was in the 
habit of using this in former years, but of late I have discon- 
tinued it, as I found the reaction from it exceedingly injurious, 
and I now look upon the warm bath as a decided injury to 
the case. I have, however, seen benefit from the application 
of a sponge soaked in hot water to the region of the larynx 
and trachea, and repeated say every fifteen or twenty minutes. 
Really this is a counter-irritant, acting by revulsion from the 
larynx, but in a great majority of cases the dyspnoea, cough 
and hoarseness diminish at once, and I have never seen 
any bad result from it. 

The food should be light and easy of digestion, and should 
consist of bread, rice, arrow-root and the various preparations 
of milk. I have seen great good follow the use of well-made 
beef-tea, a tablespoonful every two or three hours. 

Condie observes that " when the paroxysm is very violent 
and long-continued, and there is danger of the occurrence of 
asphyxia unless immediate relief is obtained, the operation 
of tracheotomy should be performed without delay. But 
under enlightened homoeopathic treatment, this must very 
rarely be necessary, save when the type of disease changes 
and the malady becomes pseudo-membranous croup. 

How can we prevent spasmodic croup? I have succeeded 
in a great many cases in which the predisposition continued 
long after the completion of the first dentition by the 
persistent use of Phosphorus, say twice a week, on going to 
bed. In addition, as a matter of course, I attended to the 



170 SPASMODIC CROUP. 

usual prophylactic treatment of children subject to this 
disease. The dress should be warm and comfortable, for the 
custom of exposing the whole of the neck and a good part 
of the chest, as well as the upper limbs and the lower ones 
from the knee to the ankle, is one of the worst follies ever 
perpetrated in the sacred name of Fashion. Children subject 
to croup should wear woollen underclothing, light but warm, 
from head to foot, and the night-dress should be made in 
the same fashion. Dr. Eberle mentions, as showing the 
influence of dress, that during a practice of six years among 
the Germans, who keep the necks and chests of their children 
carefully covered, he met with but one case of this disease ; 
and it is a comparatively rare disease in Montreal, where 
children are as rationally dressed as adults. Exercise in the 
open air should be taken whenever the weather permits, and 
the presence of snow should not be a barrier to a walk if the 
feet are properly shod. For many years I have followed the 
excellent advice of Dr. J. F. Meigs: " When the liability to 
the disease continues after the completion of the first denti- 
tion, I have found the daily use of the cold bath, in connec- 
tion always with warm clothing, most useful in preventing 
the attacks. The bath must be commenced with in the 
Summer, and persevered in through the following Winter. 
The water, after the cold weather begins, should be drawn 
in the evening, allowed to stand all night in a room in which 
there is a fire through the day, and made use of on the 
following day. Prepared in this way I have found the water 
in the morning at a temperature of between 50 and 6o° F. 
The child ought to be kept in the water only half a minute 
or a minute, then well rubbed and dressed immediately." 

Aphorisms. 

1. Spasmodic croup is a combination of catarrhal laryngitis 
and violent spasm of the interior muscles of the larynx. 

2. Boys are more frequently affected than girls, and it is 
most common during the first dentition. 



PSEUDO-MEMBRANOUS CROUP. 171 

3. Spasmodic croup is never epidemic in the proper sense 
of the word, though it is sometimes hereditary. 

4. Spasmodic croup is rarely a fatal disease, still the 
physician should not forget the fact that death may occur. 

5. Danger is present when the disease lasts. longer than 
forty-eight hours, and the danger increases with the prolong- 
ation of the attack. 

6. The homoeopathic remedies are Aconite, Spongia, 
Hepar, Phosphorus, Lobelia and Sanguinaria. 

7. The best prophylactics of spasmodic croup are warm 
clothing, judicious exercise, regulated bathing, and the 
persistent administration of Sanguinaria and Phosphorus. 



CHAPTER VIII. 



PSEUDO-M E M BR A NOU S CROUP 



This is one of the most dreaded, and, till the advent of 
the homoeopathic healing art, one of the most fatal of all the 
diseases of childhood ; and even with all the resources of the 
Similia, the thoroughly educated physician feels some little 
trepidation when he finds himself face to face with a well- 
marked case of this disease. Here, as in many other instances, 
immense advantage is derived from a thorough knowledge of 
the pathology and pathological anatomy of the disease, and 
when to this is joined a thorough knowledge of our Materia 
Medica, the homoeopathic physician is better armed than 
the practitioner of any other school whatever. The 



172 PSEUDO-MEMBRANOUS CROUP. 

contemptuous ignorance of pathology and pathological 
anatomy is thus keenly reproved by one of the most brilliant 
writers of our school : "It is because the blind application 
of our therapeutic law so often helps us when we grope 
vainly for the pathology, that we are led into a contempt for 
pathology and such allopathic studies. As healers we might 
be content with our therapeutic law ; but as physicians we 
aver it is our duty to our profession to develop its every 
branch. To-day we often do not know what we have cured ; 
and while knowing the Materia Medica will increase our 
capabilities for curing, it will not enlighten us in diagnosis 
and pathology." 

Like spasmodic croup, this disease has had a multitude of 
names, many of which are mere misnomers. Guersant calls 
it * pseudo-membranous pharyngo-laryngitis ;' Rilliet and 
Barthez style it pseudo-membranous laryngitis, in which they 
are followed by Dr. J. Lewis Smith of New York ; while 
other French writers persist in calling it laryngeal diphtheria ; 
Bsehr of Hanover calls it ' Laryngo-tracheitis Crouposa,' an 
uncouth name, but anatomically and pathologically correct. 
Fletcher of Edinburgh — most homoeopathic of all allopathic 
pathologists — selects this disease as a specimen of the prepos- 
terous names with which nosologists have labelled disease. 
" Croup, which has successively borne the names of suffocatio 
stridula (Home), catarrhus suffocativus (Hillary), cynanche 
stridula (Crawford, Wedderburn), angina inflammatose infan- 
tilis, angina epidemica (A. Miller), angina polyposa, angina 
suffocativa (Baird), asthma infantilis (Millar and Bush), 
morbus strangulosus, plastic inflammation of the air-passages 
(Laennec), diphtheritis (Bretonneau), has lately been dignified 
with the name of dento-frangibalus-broncho-laryngo-tracheitis- 
mixo-pio-meningitis, and this probably is but a single 
specimen of what we must expect if this mania be not 
resolutely checked." While some of these names are simply 
ludicrous, others are really pernicious nonsense with a distinct 
tendency to mislead the anxious physician. For example, 
Dr. Condie, one of the best writers on children's diseases on 



PSEUDOMEMBRANOUS CROUP. 173 

this continent, heads one chapter " Tracheitis-Croup ;" and 
two of the most recent writers on the subject — Sir George 
Duncan Gibb and Professor Aitken — adopt ' Cullen's erro- 
neous name of "cynanche trachealis," and Sir Thomas 
Watson styles it " cynanche-trachealis-tracheitis-croup," and 
adds: "The essence of this complaint is violent inflamma- 
tion, affecting the mucous membrane of that portion of the 
air-passages which lies between the laryngeal cartilages and 
the primary bronchi — in one word, of the trachea or zvindpipe, 
This is the genuine seat of the disease ; but the inflamma- 
tion sometimes ascends into the larynx ; and not unfrequently 
it dives into the bronchi and into their ramifications." Now, 
pseudo-membranous croup — which I conceive to be the most 
appropriate name — in a large proportion of cases, commences 
in the larynx and extends dozvnwards, and it is compatively 
seldom that it commences in the trachea and extends 
upwards, though in some cases a pseudo-membranous inflam- 
mation may extend from the bronchi to the trachea. 

Pseudo-membranous croup is an inflammation of the 
epiglottis, glottis and larynx, frequently extending to the 
trachea, and occasionally reaching to the larger bronchial 
tubes, and this inflammation is accompanied by the exuda- 
tion of a yellowish-white fibrinous material upon the mucous 
membrane of the affected parts ; the fauces and tonsils 
frequently exhibit more or less of the inflammation with its 
accompanying exudation. The disease, then, is, in the words 
of Da Costa, " not only inflammation, but inflammation 
which results in the formation of a false membrane," and it 
must be specially noted that these membranes produce no 
loss of substance, and that they leave behind them no 
cicatrices. As a result of these morbid changes the breathing 
is difficult, loud and accelerated, with shrill or wheezing 
inspiratory murmur ; the voice is at first hoarse and rough, 
but towards the close whispering or extinct ; spasm of the 
interior muscles of the larynx is almost invariably present, 
and towards the close of the disease fragments of false 
membrane are sometimes expectorated or vomitied. Fever 
is an almost invariable concomitant. 



174 PSEUDO-MEMBRANOUS CROUP. 

M. Littre, who in addition to his gigantic labors as a 
exicographer, was a medical writer of great merit, discusses 
the question whether or not Hippocrates was acquainted 
with croup, but he does not give any decided opinion on the 
matter. The following passage, however, certainly seems to 
apply to this disease : "Angina Gravissima quidem est, et 
celerrime interimit, quae neque in faucibus neque in cervice 
quicquam conspicuum facit, plurimum vero dolorem exhibet, 
et difficultatem spirandi, quae erecta cervice obitur, inducit. 
Hcec enim eodem etiam die, et secundo, et tertio, et quarto 
strangulat." Dr. Francis Adams, the learned commentator 
on Hippocrates and Paulus Aegineta, considers that there 
can be no doubt that the ancients were well acquainted with 
that species of cynanche in which the disease spreads down 
to the windpipe. Few of us, however, would agree with Dr. 
Adams when he says, " It may reasonably, be doubted 
whether they (the ancients) were not fully as well acquainted 
with diseases of the fauces and windpipe as the moderns 
are." Baillon (Paris, 1576) was the first writer of modern 
times to describe this disease, " Chirurgus affirmavit se 
secuisse cadaver pueri ista difficili respiratione et morbo (ut 
dixi)incognito sublati ; inventa est pituita lenta, contumax, 
quae instar membranae cujusdam arteria aspera erat obtenta, 
ut non esset liber exitus et introitus spiritui externo , sic 
suffocatio repentina." According to Fredrich, Baillon was 
the first who mentions having dissected a patient who had 
died of croup. Boerhaave and Willis describe morbid states 
strikingly like croup, and the " suffocative catarrh " of 
Ettmiiller is clearly croup under another name. Dr. Blair 
of Cupar Angus, in Scotland, first described the disease by 
its present name, in the year 171 3. " The tussis convulsiva 
or chink-cough, is also some years epidemical, and becomes 
universal among children ; as is a certain distemper with us 
called the croops, with this variety, that whereas the chink- 
cough increases gradually, is of long continuance, seizes in 
paroxysms, and the patient is well in the interval ; this 
convulsion of the larinx, as it begins so it continues, so 



PSEUDO-MEMBRANOUS CROUP. I 75 

violently that unless the child is relieved in a few hours 'tis 
carried off within twenty-four, or at most forty-eight hours. 
When they are seized they have a terrible 'snorting at the 
nose and squeaking in the throat, without the least minute 
of free breathing, and that of a sudden ; when perhaps the 
child was but a little time before healthful and well. The 
most immediate cure is instant bleeding at the jugular, 
either by the lancet or leeches ; when the most urgent 
symptoms are gone, then emetics or the like are adminis- 
tered at discretion." Two French writers, Molloi and Malain, 
described the disease in 1743 and 1745 respectively; in 1749, 
Ghizi, of Cremona, gave a good account of it under the 
name of angina strepitosa, and in the same year it was 
described by Dr. Starr, of Liskeard, in Cornwall. In 1755, 
Dr. Richard Russell, of London, described the disease as 
observed by him in connection with the epidemic sore-throat 
then raging, and he points out that " it is most apt to seize 
children from two years old to eight or ten, but chiefly the 
younger sort " — most probably laryngeal diphtheria. Dr. 
Francis Home's essay, entitled "An Enquiry into the Nature, 
Cause and Cure of Croup," appeared in 1765, a carefully 
written account of true croup as observed in Edinburgh and 
the neighboring towns at a time when the disease was not 
complicated by epidemic affections of the fauces. Home 
regarded the disease as an acute inflammation of the larynx 
and trachea, and his descriptions, with those of his Swedish 
contemporaries, Halen and Wahlbom, gave croup a definite 
place among diseases. Millar, who practiced in Scotland at 
a later date than Home, published his " Observations on the 
Asthma and Hooping Cough," in 1796, and he gives greater 
prominence to the spasmodic element in the disease than 
any previous writer — indeed he seems to have spasmodic 
croup in his mind's eye more than the true croup of Home. 
Some of these writers, notably Ghizi of Cremona, and 
Starr of Liskeard, were describing what we would call 
diphtheritic croup, and Dr.Richard Russell was clearly describ- 
ing an epidemic angina which often extended to the larynx 



176 PSEUDO-MEMBRANOUS CROUP. 

and trachea, and which was entirely distinct from the 
sporadic and purely inflammatory disease so ably described 
by Home. The latter writer thus contrasts the two diseases : 
" The two very different situations of the suffocatio stridula ; 
the former more inflammatory and less dangerous ; the latter 
less inflammatory and highly dangerous ; in the former the 
pulse is generally strong, the face red, drought great, and 
they agree with evacuations ; in the latter the pulse is very 
quick and soft, great weakness, tongue moist, less drought, 
great anxiety, and evacuations hasten death." In spite of 
these clear diagnostic differences, many epidemics of angina 
maligna — which would now be styled diphtheria — in the 
eighteenth century were called croup, just as not a few cases 
of laryngeal diphtheria are included in the accounts of croup 
written near our own day. 

In the first year of the nineteenth century, Cheyne pub- 
lished in his " Essays on the Diseases of Children," a treatise 
on cynanche trachealis in which he maintained the views of 
Home with great ability, and many years later the same 
learned physician wrote the article on croup in the Cyclopcedia 
of Practical Medicine, in the hands of so many practitioners 
on this continent. From 1805 to 1807, a great epidemic of 
croup, so-called, swept over the western part of the continent 
of Europe, and among its most illustrious victims was the 
Crown-Prince of Holland, nephew of Napoleon the Great 
and brother of Napoleon III. His uncle, who was tenderly 
attached to the lad, ordered the institution of the famous 
Concours on croup,- and of the 83 essays sent in, though many 
describe diphtheritic croup, the writers who carried off the 
principal prizes, Jurine of Geneva and Alhers of Bremen, 
unquestionably describe an independent disease, inflamma- 
tory in its nature, uncomplicated by malignant angina or any 
epidemic influence whatever. Still later in point of time, we 
had a controversy, hardly terminated, between the observers 
who contended that there was but one form of croup, and 
that other body of practitioners who drew a sharp line of 
demarcation between pseudo-membranous croup and 
spasmodic croup. 



PSEUDO-MEMBRANOUS CROUP. J 77 

In the last chapter the writer remarked upon the fact that 
spasmodic croup is much more frequent than the pseudo- 
membranous variety, and it was stated that while spasmodic 
croup is a disease of very young children, pseudo membran- 
ous croup generally affects those of more mature years. 
Cullen remarks, " This disease seldom attacks infants till 
after they have been weaned. After this period, the younger 
they are, the more they are liable to this disease. The 
frequency of it becomes less as children become more 
advanced ; and there are no instances of children above 
twelve years being affected with it." The last assertion is 
unquestionably an error, for it has been often seen in its most 
formidable form in children at the breast, and adults have 
died from it. Bsehr of Hanover questions whether adults 
have ever died of genuine croup, and he remarks that it 
occurs even less frequently before the second than after the 
seventh year. This last remark is not in harmony with the 
experience of any other writer, and is contradicted, moreover, 
by the Vienna statistics, noted for their accuracy. " Among 
501 deaths from croup in Vienna, during 1868, 92 were in 
the first year (30 were 12 months old, and 12 were 1 1 months), 
128 in the second, Sy in the third, 71 in the fourth, 50 in the 
fifth, 34 in the sixth, 17 in the seventh, 7 in the eighth, 6 in 
the ninth, 2 in the tenth and eleventh respectively, 3 in the 
twelfth, 1 in the thirteenth, and 1 in the sixty-second." 
(Glatter.) Dr. Condie says that in Philadelphia, during the 
ten years preceding 1845, 3 X 9 deaths were reported from 
croup in infants under one year ; 238 in those between one 
and two years ; 475 in those between two and five years ; 1 12 
in those between five and ten years ; and 6 in children over 
ten years. " Of 2,136 fatal cases reported in this city (Phila- 
delphia) during the seven years from 1862-68, 301 were under 
1 year of age ; 571 between 1 and 2 years ; 951 between 2 
and 5 years; or, 1,522 between 1 and 5 years; and 236 
between 5 and 10 years ; leaving but yy cases as occurring 
after the latter period of life (Meigs and Pepper). The 
same writers add that of the 35 cases that they have seen, 



178 PSEUDO-MEMBRANOUS CROUP. 

28 occurred between 2 and 7 years of age, while of the 
remaining 7, 1 occurred at the age of 18 months; 1 at that 
of 19 months; 1 at 7J years ; 2 at 1 1 years, and 1 each at 
n 3 and 12J years. In 1870, 4,302 children died of this 
disease in England, of which 3,663 were under five years of 
age, and the largest number of deaths was amongst those in 
their second year. Instances are reported in which the dis- 
ease occurred at a very early age. Morley and Cheyne 
speak of having seen it in infants of less than three months, 
and Bouchut has seen it in one only eight days old. Dr. 
Home remarks that the younger children are when weaned, 
the more liable are they, cceteris paribus, to this malady, 
and this has been confirmed by Cheyne and other excellent 
observers. 

In contrast with whooping-cough which principally affects 
female children, pseudo-membranous croup is much more fre- 
quent among males than females, though Meigs and Pepper 
state that "sex cannot be said to exercise any decided influ- 
ence upon the frequency of this disease," and in support of 
this statement, they point out that of the above-mentioned 
2,136 cases, 1,115 occurred in males and 1,021 in females. 
Dr. Squire is almost of the same opinion as the distinguished 
Philadelphia writers. He says : " More boys than girls are 
born in a proportion somewhat greater than one in every 
fifty children, or, to give the result of a very extended exam- 
ination, there are 511.75 males and 488.25 females in every 
1,000 births ; it appears that of this number 83.71 males and 
65.74 females die within the first year, after which the 
death ratio of the two sexes for the next ten years is 
nearly equal ; still there are a larger number of males than of 
females living at that period, and the deaths of females from 
all causes are to those of males as 87 to 100 in the first five 
years, or as 88 to 100 in the first ten years. Now the deaths 
from croup are so nearly in this proportion, and of late years 
have so often shown a difference so much less than this, that 
a doubt might be entertained as to whether any difference 
in the liability of the sexes really existed. A comparison 



PSEUDO-MEMBRANOUS CROUP. 1 79 

between the deaths from all causes of each sex for each year 
with the deaths from croup at each year, sex with sex, shows 
a difference of excess on the side of the males so constant 
that it is rare to meet with an exception, but at the same 
time so slight that it can only be considered a characteristic 
of the disease in the aggregate, corresponding with the 
results of pneumonia and tubercular meningitis rather than 
with the more characteric zymotic diseases, and contrasting 
with those of diphtheria and whooping-cough, where the 
excess of deaths is greatly on the side of the females." 

On the other side of the question, without giving figures, 
Felix von Niemeyer states that " boys are more subject to 
it than girls," and Bsehr thinks that from 60 to 70 per cent. 
of all cases are boys. Of 429 deaths from this disease in 
Massachusetts during 1852, 243 were in boys and 178 in girls. 
Of Steiner's 101 cases, JJ were boys and only 24 girls ; of 
30 cases reported by Trousseau 22 were males and 8 females. 
Of Bohn's 70 cases 43 were boys and 2J were girls, while of 
Jauseconich's ' 22 cases 17 were boys and 5 were, girls. 
Ruehle giving the proportion of boys to girls as 3 to 2 ; and 
the deaths from croup in the London Hospitals during the 
year 1840 were three in the male sex to one in the female. 
Glatter makes the curious observation that among the Chris- 
tian population of Vienna the mortality from croup is 2.6 
per cent., while among the Israelitish it is 4.2 per 
cent, and Steiner confirms this from his own experience 
in Prague. The writer's own experience is, that not only is 
the disease more frequent in males than in females but it is, 
at the same time, more severe and more fatal, so that a little 
girl's chances of life are much brighter when attacked with 
pseudo-membranous croup than are the chances of a little 
boy. 

Almost all observers are agreed that pseudo-membranous 
croup is largely a malady of children of sanguineous temper- 
ament, plump and of ruddy complexion, and apparently in 
the enjoyment of excellent health. Drs. Meigs and Pepper 
remark of their 35 cases that 26 occurred in healthy, vigorous 



l8o PSEUDO MEMBRANOUS CROUP. 

children, while the remaining 9 occurred in children who 
though neither very weak nor very sickly, presented a rather 
delicate appearance. Steiner, in one article on croup, 
says " that true croup appears by preference in strong 
children, well nourished and previously healthy, and in 
another paper, of later date, he says that " strong, well-fed, 
hearty children are no more liable to croup than those who 
are feeble, delicate, or affected with other diseases." Felix 
von Niemeyer is the most distinguished writer who contra- 
dicts this view, so generally held : " It is an error to suppose 
that vigorous, full-blooded, blooming children are especially 
liable. On the contrary, tender, delicate ill-nourished off- 
spring of tuberculous parentage, with pale skin and conspic- 
uous veins (an ominous sign even for the laity),~ children 
with a tendency to moist eruptions, to enlarged lymphatics, 
or to acute hydrocephalus, suffer from croup with equal or 
even greater frequence than those who are more robust. It 
is our daily experience that, in the great mortality which 
desolates certain families, a portion of the members die of 
croup, and another of hydrocephalus, while in the survivors 
pulmonary tuberculosis develops later in life. It would 
appear that the croup not unfrequently begins very soon 
after the disappearance of a moist eruption on the head or 
face." 

I consider that season and temperature exercise a much 
more powerful influence than constitution and temperament 
upon the development of true croup, for, like the spasmodic 
croup, it is, as Cullen remarks, ' often manifestly the result 
of cold applied to the body,' especially of sudden transitions 
from heat to cold. Professor Golis of Vienna relates the 
case of a boy four years old, previously in perfect health, 
who, having gone out from an over-heated room into the 
open air during an extremely cold winter's day, was seized 
while walking with all the symptoms of the most violent 
croup, which proved fatal in fourteen hours. It is most 
common during cold, damp, changeable weather, and it often 
attacks children who live in over-heated rooms and who are 



PSEUDO-MEMBRANOUS CROUP. l8l 

taken into the open air without proper clothing, especially 
during keen east or north-east winds, or the prevalence of 
sudden changes of temperature. Croup is four times as 
frequent in the winter quarter, November, December and Jan- 
uary, as in the summer quarter, June, July and August. Dr. 
J. Lewis Smith notes that it is common among the poor of 
New York, who live in close rooms, over-heated during the 
days and cool at night, and Drs. Meigs and Pepper formu- 
late the opinion of the profession by saying : " The mean 
monthly temperature and the mean monthly mortality from 
croup rise and fall together throughout the entire year!' 

Dr. Cheyne thought that the liability of children to this 
disease depended upon the narrowness of the chink of the 
glottis, and in support of this Drs. Evanson and Maunsell 
pointed out that there is "scarcely any perceptible difference 
between the aperture of the glottis of a child of three and 
one of twelve years of age ; while, after puberty, that 
opening is suddenly enlarged, in the male, in proportion of 
ten to five, and in the female, of seven to five." Guibert 
thought that the straightness of the windpipe and particu- 
larly of the glottis, "rendered croup more frequent in infancy, 
but is difficult to see how it could have this effect." Finally, 
without going as far as Meigs and Pepper, who frankly 
admit that' " in none of the cases that we have seen could 
the exciting cause be even suspected." I would remark 
that in very many cases the exciting cause is absolutely 
inscrutable. 

Does true croup — pseudo-membranous croup — ever recur 
in the same patient ? Dr. William Squfre, of London, who 
has bestowed extraordinary pains on the etiology of this 
disease, is confident that it does recur: "Children who have 
suffered an attack are specially liable to a recurrence on 
exposure to any of these causes (exposure to cold, change 
of dress, etc.), and the recurrent attack is not always the 
least severe." Yet Dr. Squire is unquestionably describing 
true croup — not spasmodic croup — which was certainly in 
the minds of Evanson and Maunsell when they wrote " when 



1 82 PSEUDO-MEMBRANOUS CROUP. 

a child has once been affected with croup, it must be consid- 
ered liable to a recurrence of the disease at any period until 
the arrival of puberty." Steiner remarks that true croup, as 
a rule, occurs in the same child once only, though there are 
a few occasional instances of a second attack, and in his own 
experience of more than a hundred thousand cases of disease 
among children, he has never yet met with a single recur- 
rence of true croup. Meigs and Pepper had two patients in 
whom second attacks occurred, a very large proportion of a 
total of 35 cases. The writer never met with a recurrence 
of pseudo-membranous croup, and stories such as that told 
us by Dewees, who claimed to have attended a lady of forty 
for five attacks of croup within six years, are just so many 
illustrations of the ignorance of the distinction between true 
croup and spasmodic croup. I am quite willing, however, 
to admit the correctness of Bsehr's observation, " if a child 
has been once attacked with croup, it retains an increased 
disposition to inflammatory affections of the larynx." But 
these " inflammatory affections " rarely assume the form of 
pseudo-membranous croup. 

Steiner speaks of " a certain hereditary and family dispo- 
sition to croupous inflammation in general, and to laryngeal 
croup in particular," and in discussing the subject he says, 
" I have quite recently become acquainted with two unfortu- 
nate families, in one of which all four, and in the other all 
three children died of membranous croup, within five years in 
the one case, and within four years in the other." I submit 
that unless Steiner can prove that the parents of these 
children had had membranous croup in infancy, it is clearly 
incorrect to speak of an hereditary disposition, though these 
are probably illustrations of a family predisposition, which 
is not so marked in true croup as in the spasmodic variety 
of the disease. It is but fair to admit that many writers of 
note vehemently deny that any such family predisposition 
exists. About twenty-two years ago I attended two families 
in whom the disease appeared in every child during the 
second or third year of life. The children were six in 



PSEUDO-MEMBRANOUS CROUP. 1 83 

number, of whom I lost three ; of these one was moribund 
when I first saw it. 

Pseudo-membranous croup is, generally speaking, a spora- 
dic disease, and though not so frequently seen as spasmodic 
croup, it is by no means such a rare occurrence as Cullen 
supposed it to be. Many writers contend that it is occasion- 
ally epidemic, and Dr. Churchill gives us a most formidable 
catalogue. " The principal epidemics of which we have 
authentic accounts are those of Paris in 1506 (Baillon) ; 
Cremona in 1747 (Ghizi) ; Cornwall in 1748 (Starr) ; Upsal, 
1762 (Rosenstein) ; Frankfort in 1764 (Van Bergen) ; Sweden 
in 1768-72 (Wahlbom and Bceck) ; Wertheim in 1772 
(Zobel) ; in Galicia, in 1778 (Hirshfeld) ; Clausthal in 
1783 (Bcehmer) ; the United States in 1805 (Barker); 
Stuttgard,in 1807 (Autenrieth) ; Saxony, in 1807-8 (Albers) ; 
and again, in 181 1 (Schundtmann) ; at Vienna, 1807-8 
(Golis) ; and in Maryland, in 1807 (Chatard)." Bouchut is 
quite certain that the disease is epidemic: "Croup is an 
epidemic disease. This characteristic is a difficult one to 
establish at Paris, where most of the cases are disseminated 
and lost as regards each medical man who is limited to a 
portion of the field of public health. There, there is no 
general epidemic ; only partial epidemics are observed 
developed in a quarter, in a house, or in a hospital devoted 
to infants. Still more must these epidemics be declared 
very unfrequent, for only one has been observed at the 
hospital for children at Paris, and that not very well charac- 
terized. The epidemic character especially reveals itself, in 
limited localities. It is impossible to mistake.it when it is 
observed in a province and in districts where nothing is 
ignored, and where the ravages caused by .this disease in the 
population can be closely followed." Dr. J. F. Meigs 
remarks: " When epidemic, it is very generally connected 
with angina, while the sporadic cases frequently begin in the 
larynx, and often run their course without implicating the 
pharynx. During the latter part of the year 1844, the whole 
of 1845, and a part of 1846, the disease prevailed exten- 



1 84 PSEUDO-MEMBRANOUS CROUP, 

sively in this city, and was in many cases accompanied 
by the pharyngeal affection. During these years, and 
particularly in 1845, measles and scarlatina also prevailed to 
a great extent, especially the former." Steiner says that, 
" Primary croup occurs sometimes sporadically, sometimes, 
though less frequently, as an epidemic. When several chil- 
dren in a family, or a large number in a neighborhood, are 
affected with the disease, most of such instances belong 
generally to the epidemic form ; but this distinction has not 
been sufficiently observed in the literature of croup to make 
it available for statistical purposes.'' " Not unfrequently," 
says von Niemeyer, " we observe its epidemic appearance. 
At such times many children are attacked, even in one small 
place, and often several children of the same family in quick 
succession, and by the most intense and pernicious form of 
the disease.'' Condie is as positive on this point as his dis- 
tinguished townsman, J. F. Meigs : "Of the frequent prev- 
alence of croup as an epidemic, Berge, Canstatt, Fleury, 
Valleix, Wunderlich, 'and others, furnish incontestable evi- 
dence. An epidemic of the disease is recorded as having 
extended over the greater portion of Central Europe during 
the period between 1805 an d 1807, and one of more circum- 
scribed limits by Ferrand in his Thesis on Membranous 
Angina, published in 1827, during which, in a district of very 
small extent, there occurred no less than sixty cases of croup, 
all terminating fatally." The writer has seen two epidemics 
of pseudo-membranous croup of limited extent, and in both, 
the disease commenced as an intense pharyngitis, which, 
however, was neither diphtheritic nor scarlatinous in its 
nature. One of these epidemics, which appeared in the year 
1859 was the immediate forerunner of a very severe epidemic 
of diphtheria, of which but few cases affected the larynx. 

Little has been written as to endemics of pseudo-membra- 
nous croup, but a number of years ago a series of facts was 
observed by the writer which leads him to believe that the 
disease may occasionally rage as an endemic. Briefly, the 
facts are as follows : A family, the children of which had 



I'SttUDO-MEMBRANOUS CfcOtJ t8§ 

not been subject to croup, moved into a house situated near 
a low and stagnant creek, and very soon several of the 
children had severe attacks of true croup. After a very 
sickly time, that family removed to another house and a 
second family took their place. But soon the second family 
was attacked by true croup in a very severe form, and they, 
too, concluded to change their quarters. Neither of these 
families had croup either before or after their resi- 
dence in that house, the subsequent medical history of 
which I have been unable to trace. I have observed some 
other cases less marked than the above, and in my native 
city of Edinburgh the disease has been noted to prevail as 
an endemic in the Cowgate, which is a long and very squalid 
street, occupying the deepest part of a valley densely 
crowded by buildings of a very unhealthy nature. Sir 
Thomas Watson remarks: "Towns situated on the banks of 
rivers have more than the average share of it ; and it has 
been observed to be particularly frequent among the children 
of washerwomen in such places, and thus evidently connected 
with exposure to moisture. In towns so situated, it has been 
known to prevail epidemically after an inundation." 

Is pseudo-membranous croup contagious? This question 
is clearly wrapped up with the question of the identity or 
non-identity of pseudo-membranous croup and diphtheritic 
croup, which is fully discussed in the next chapter, but for 
the sake of completeness, the question of contagion will be 
considered here. Aitken avoids the question altogether : 
" While the annals of medicine are rich in descriptions of 
epidemic and endemic croup, opinions are very much divided 
as to the nature of the epidemic influence, and whether or 
not the disease is contagious or infectious." Bouchut main- 
tains the contagious nature of croup, but his remarks 
eviedntly apply to diphtheritic croup : " Its contagious 
nature is far from being demonstrated ; still this question 
must not be answered in the negative, for croup often follows 
pseudo-membranous angina. Now, the contagion of this 
latter disease has been demonstrated in the most positive 



186 KSEUlDO-MEMBRANOUS CROUP. 

manner by the observations of M. M. Bretonneau and 
Trousseau. It is, then, possible that croup, which by its 
nature very much resembles pseudo-membranous angina, 
may, like it, be transmitted by contagion. I say possible, 
for in the present state of science a more positive expression 
cannot be made use of. It is, consequently, proper to 
separate those children laboring under croup from other 
children whose health has not, as yet, experienced any 
attack." In a similar strain Churchill remarks : " Several 
authors, Wichmann, Bcehmer, Field and others, maintain the 
contagiousness of croup ; but this is denied by the majority 
of writers, at all events in the case of primary croup. Certain 
forms of diphtheritic inflammation of the fauces and pharynx 
are undoubtedly contagious ; and as the inflammation and 
exudation sometimes spread to the larynx, constituting 
secondary croup, it may be so far regarded as sharing in the 
same mode of propagation." Steiner says, " Some authors 
regard ordinary inflammatory croup as infectious, but with 
this I do not agree, though there can be no doubt that the 
diphtheritic variety is eminently contagious ;" and again, in 
a later paper, " Primary croup occurs sometimes sporadically, 
sometimes, though less frequently, as an epidemic. When 
several children in a family, or a large number in a neighbor- 
hood, are affected with the disease, most of such instances 
belong generally to the epidemic form ; but this distinction 
has not been sufficiently observed in the literature of croup 
to make it available for statistical purposes." Baehr tersely 
says " that croup is contagious is only believed by those who 
regard croup and diphtheria as identical," and Condie is 
equally explicit : " Under no circumstances do we believe 
croup to be contagious." Felix von Niemeyer observes: 
" In some croup-epidemics facts have been observed which 
make it somewhat probable that the disease may spread by 
contagion. It is questionable, however, whether there may 
not have been confusion with that highly-contagious malady, 
epidemic diphtheria ; in these cases, as we shall hereafter 
demonstrate, the fact that secondary croup of the larynx 



tSEUDO-MEMBRANOUS CROUP. lS? 

often accompanies diphtheria of the fauces." Copland says, 
" it has most indubitably manifested this property (contagion) 
when it has prevailed epidemically, and when associated with 
cynanche maligna " — which, in our day, would be styled 
diphtheria. My old clinical teacher, George B. Wood, writes : 
"The disease has also been ascribed by some writers to 
epidemic and contagious influences. But, if we except the 
cases which are apt to occur during the prevalence of 
epidemic catarrh, it is only to the diphtheritic disease of 
Bretonneau that this remark is applicable. Original, uncom- 
plicated croup is probably never either epidemic or conta- 
gious." Pseudo-membranous croup, then, may safely be set 
down as being non-contagious, while the reverse is the case 
with diphtheritic croup, and, personally, I agree with Dr. 
Squires : " Croup, indeed, seems to hold a place intermediate 
between the zymotic class and those of the respiratory 
organs." 

As a general rule, true croup is a primary disease, but 
occasionally it is secondary ; indeed, physicians are only now 
realizing the truth of Lefferts' remark, " Unquestionably in 
the majority of cases of acute infectious disease the larynx is 
more or less implicated." West defines secondary croup to 
be " that form which occurs in the course of acute, infective 
or general constitutional diseases, pysemic processes and 
other acute or chronic affections." Measles is said by all the 
writers who have touched on this phase of the disease to be 
the malady most frequently complicated with croup, but 
though I have attended a very large number of cases of 
measles, I have never seen the disease complicated with 
croup in any form. Very rarely does croup complicate 
measles in the commencement ; more frequently is it seen at 
the height of the eruption ; and it generally occurs during 
the stage of desquamation. Spasmodic and catarrhal croup, 
on the contrary, usually attack during the very onset of 
measles, and West points out that pneumonia, in all its 
stages, is far from being unusual, and is a complication 
especially to be feared in those cases where croup occurs as 



188 PSEUDO-MEMBRANOUS CROUP. 

a secondary affection in the course of measles. Scarlatina 
is often complicated with a very fatal form of true croup, 
and as the subject is of importance, I have devoted a brief 
chapter to the consideration of it, to which the reader is 
referred. Less frequently than scarlatina, small-pox is com- 
plicated with croup, and in a practice among children 
extending over thirty years, I have seen the complication 
somewhat frequently in scarlatina and small-pox, but never 
in measles. In November, 1871, I attended a child, in whom 
vaccination had been neglected, for confluent small-pox. 
The case, though very severe, did well till, worn out with 
watching, the mother did not notice that the child had 
slipped from the bed to the floor. It lay there for three or 
four hours, as nearly as could be ascertained, and when 
taken up pseudo-membranous croup was fully developed, and 
the child died in twenty-four hours. Again, a young man, 
unvaccinated and suffering severely from primary syphilis, 
was attacked with a malignant form of small-pox. Almost 
immediately the larynx was attacked and the patient died 
in twenty hours. Steiner has twice noticed pseudo-membra- 
nous croup during the height of whooping-cough, and it has 
also been seen in the course of typhoid fever. 

Croup is found in every country and in all climates, yet it 
is more influenced by peculiarities of country and climate 
than any other disease of the respiratory organs. Hirsch 
points out that it diminishes in frequency as we approach 
the tropics, yet Sir James M'Grigor notes its prevalence at 
Bombay in the year 1800 — but as it attacked adults, it was 
most likely diphtheritic croup. A cold and moist atmosphere, 
with rapid alterations of temperature, and the vicinity of the 
sea, make up the climate in which croup may almost be said 
to be endemic, and when to these are added an unknown 
yet very tangible epidemic influence, croup becomes a 
veritable scourge. According to Bsehr, the flat country 
extending from Hanover to the North Sea is frequently 
visited by croup, and he remarks that the winds blowing in 
this region of country must be possessed of a peculiar nature 



PSEUDO-MEMBRANOUS CROUP. 1 89 

in order to cause extensive epidemics which sometimes 
snatch away twenty or more children in a single village. 
"That croup is caused by a simple cold, is much more easily 
asserted than proven. The same child has many attacks of 
violent laryngeal catarrh in the course of the year, but is 
attacked with croup only during the prevalence of a keen 
blast from the north." In Scotland the greatest mortality 
from croup is not found in the extreme north, but on the 
western and eastern coasts, deeply indented by the sea, 
which leaves a great expanse uncovered at every tide, and 
when to these conditions is added the keen easterly winds, 
croup rages with a great mortality, often exceeding two per 
cent, of all diseases. The disease is not nearly so frequent 
in Scotland as it was when Cheyne first wrote, for the low, 
marshy grounds have been extensively drained, thus affording 
another illustration of the pernicious influence of moisture. 
The influence of an equable temperature is strikingly shown 
by the low mortality from croup in the counties of Wigton 
and Dumfries in the southeast of Scotland. Here the 
temperature, though occasionally low, is, on the whole, more 
equable than in most parts of the kingdom, and the croup 
mortality is always below one per cent., sometimes touching 
0.5. West remarks upon the comparative rarity of croup in 
towns, and its frequency in rural districts, stating that "out 
of 100 children dying under five years of age from all causes, 
more than four times as many will have died from croup in 
Surrey as in Liverpool, and exactly four times as many as in 
London." Yet, according to Squire, the highest croup mor- 
tality in England is in the populous districts of Lancashire 
and Cheshire, where, especially in the first-mentioned county, 
the towns and villages almost touch each other. There can 
be no doubt that in a dense urban population, with defective 
drainage and a variable climate, croup must rage with 
peculiar virulence. "According to the investigations of later 
years, which indeed are still incomplete, it appears as though 
the amount of ozone in the air acted an important part as 
one of the causative influences of croup. This is so much 



190 PSEUDO-MEMBRANOUS CROUP. 

more probable since the amount of ozone contained in the 
air is liable to the greatest variations during the prevalence 
of abnormal proportions of electricity such as are apt to be 
caused by a northwest wind " (Bsehr). 

Dr. Elb, of Dresden, questions whether it would not be 
more correct to ascribe croup, according to the law similia 
similibus, to the presence of certain component parts in the 
exhalations from the sea, particularly chlorine, bromine and 
and iodine, which may act as exciting causes. He proceeds 
to point out that iodine can produce croupous symptoms, 
and quotes an observation of Leroy's that, by the accidental 
respiration of chlorine, symptoms of suffocation were pro- 
duced, and afterwards concretions were expectorated which 
very much resembled the false membrane of croup. 

The disease may commence suddenly and almost without 
premonition, but usually it commences with uneasiness and 
slight shivering, which may not be noticed in an infant. In 
children of robust constitution, whose general health is good, 
the disease is apt to come on without premonitory symp- 
toms, but in children of average constitution, the precursory 
stage is quite distinctly marked. Again, in the debilitated, 
or in the scrofulous, the grade of inflammation may be low, 
almost without fever, and exudation closely follows on 
inflammation. The precursory symptoms are really those of 
an ordinary catarrh, such as feverishness, sneezing, cough 
and hoarseness. Baehr says that " in very rare, or rather 
exceptional, cases, croup is preceded by a nasal catarrh, 
which, when present, is a tolerably certain guarantee against 
the possible occurrence of croup." The rough cough and 
the hoarseness are symptoms that should excite attention, 
for in a young child they are never wholly devoid of danger, 
and I am satisfied that many lives have been lost from want 
of attention to this indication. Drs. Evanson and Maunsell 
urge us to look with suspicion upon these two symptoms — 
hoarseness and rough cough — for we can never be too early in 
our recognition of croup. Note that this cough differs from 
the cough of spasmodic croup in being less hoarse and more 



PSEUDO-MEMBRANOUS CROUP. . 1 91 

sonorous. The eyes are suffused and the child is drowsy, and 
I am inclined to believe that the latter symptom is much 
more marked than it is in an ordinary catarrh'. The respira- 
tion is not irregular except after exertion, and there is slight 
pain on swallowing, with vague uneasiness in the larynx; but 
these symptoms are almost wholly unnoticed in infants, and 
are likely to be overlooked even in older children. The 
little patient is chilly at times and the chilliness is succeeded 
by heat of the skin, with lassitude and loss of appetite. 
The pulse is frequent and a little harder than usual, and 
the countenance is slightly flushed. This is, of course, a 
catarrhal fever, but not every catarrhal fever develops into 
croup, even when the laryngeal complication is quite marked ; 
for, in the words of Dewees, " it would appear that it is not 
sufficient for the production of croup that the mucous 
membrane of the windpipe be merely inflamed ; but that it 
requires a modification of inflammation to induce it." The 
two indications, then, which should suggest croup to the 
mother are roughness of the voice and hoarse cough. If at 
this stage the throat be examined— and an examination 
should never be neglected — it will be found that, even in 
cases in which the child has not complained of difficulty in 
swallowing, there is more or less congestion of the fauces, 
with exudation of small, pearly, fibrinous spots on the soft 
palate, uvula, tonsils and posterior wall of the pharynx. 
These spots are at first mere islands, but they soon spread, 
and when found in conjunction with the rough and husky 
voice and the hoarse cough, a morbid state is revealed which 
should awaken the gravest apprehensions. This entire 
morbid state, of course, as Dr. Squires points out, follows 
quickly upon the cause which excited it, and it may last for 
three or four days, though it very seldom precedes the out- 
break of the disease more than twenty-four or thirty-six 
hours. Even from the very commencement all the symp- 
toms are aggravated at night, and nocturnal exacerbations 
are the rule throughout the disease. As Dr. Charles West 
accurately remarks, " thirty-six hours seldom pass^ without 



192 PSEUDO-MEMBRANOUS CROUP. 

the supervention of some symptom which, to the well- 
schooled observer, would betray the nature of the coming 
danger." But the precursory stage may be absent, and in 
the robust or in the scrofulous the laryngeal inflammation 
followed, or rather accompanied, by exudation, may be the 
first intimation of danger. Professor Wood says : " I once 
attended the case of a little girl who, when first visited, was 
running about the apartment with no other apparent disease 
than a whispering voice, and perhaps some little difficulty of 
respiration ; yet she was at that moment almost as surely 
condemned to death as though she had been already in the 
last stage of the disease ; for the membrane was already 
formed, and no efforts could prevent its fatal progress." The 
writer has attended a number of cases in which, after some 
over-exertion at play, or after exposure to cold, children 
were attacked without warning; but this sudden onset is of 
rare occurrence. Sometimes pseudo-membranous croup is 
developed in the course of spasmodic croup — especially if 
the child has had repeated attacks — and the possibility of 
this should be kept in view by the mother and by the 
physician. 

The outbreak of the fully developed disease almost always 
takes place about midnight. The early part of the night 
may be passed in quiet sleep, but the child is suddenly 
aroused by a severe paroxysm of cough, or, more rarely, by 
a series of coughs, gradually increasing in number and 
violence. This second stage is marked by a change in the 
character of the cough, which has a ringing, brassy clangor, 
which can never be forgotten when once heard. Evanson 
and Maunsell say that the cough is sharp and ringing, as if 
passed thro-ugh a brazen trumpet, and Baehr compares it to 
the bark of a watch-dog, but all comparisons poorly picture 
its ominous, ringing resonance. This change in the character 
of the cough heralds a change in the respiration, which 
becomes prolonged and stridulous — a loud rattling noise 
succeeding each inspiration as well as each paroxysm of 
cough. In the most severe cases this loud, rattling noise 



PSEUDOMEMBRANOUS CROUP. I93 

accompanies the expiration as well as the inspiration. The 
inspirations are audible, wheezing and much longer than 
normal, and the respiratory acts are greatly more frequent than 
in health, from 28 to 36 to the minute, occasionally as high 
as 48. The paroxysms of dyspnoea are of the most frightful 
character. The child sits up in bed, stretches his head back- 
wards, and instinctively does all he can to force air through 
the narrowed glottis. The hoarseness, which was present 
during the first stage, is now replaced by an almost complete 
suppression of voice, which falls to an almost inaudible whis- 
per. The cough loses its ringing, sonorous sound and 
becomes dry, husky, and apparently confined to the throat. 
It is distinctly paroxysmal, and though it is sometimes 
frequent, in other cases it occurs at long intervals, and I have 
noted that the frequent cough is a more favorable sign than 
the rare cough, while the complete or almost complete 
suppression of cough is a very bad sign indeed. As the second 
stage progresses, the cough becomes shorter and more 
smothered, till as Dr. Meigs remarked, " it might very well 
be called whispering." The breathing now becomes still 
more difficult, the cough assumes the muffled and husky 
character, the gestures of the child indicate pain in the 
throat or upper part of the sternum, the face becomes swollen 
and darkened, the anxiety and unrest becomes excessive, 
and all the symptoms indicate approaching suffocation. The 
little one starts up in bed and begs piteously to be taken in 
his mother's arms, immediately he entreats to be put back to 
bed again ; he grasps his windpipe as if he would tear out 
the obstruction to respiration ; he tosses about in his crib, 
catching at its sides in his agony ; the face is livid and dis- 
torted ; the red and swollen eyes almost start from their 
sockets ; the veins in the head and neck are thick and blue 
and cord-like ; cold perspiration covers the brow, yet the 
cough, in spite of the most desperate exertions, is still 
soundless, accompanied by the expectoration of a very little 
tenacious mucus, mingled with froth. " In a word," says 
Steiner, " we have before us the heartrending picture of a 



194 PSEUDO-MEMBRANOUS CROUP. 

child nearly suffocated, tortured with the death-pang ; a 
picture which draws out all our compassion, and brings home 
to us, as few other diseases do, the painful side of our 
calling." 

In the early part of the attack there is no expectoration, 
or perhaps a little viscid mucus ; but during the second stage 
there may be expectoration of false membrane in small 
pieces, mixed with ordinary mucus. Dr. Meigs says that to 
" detect the membrane, the substance expectorated or 
vomited ought to be placed in water, when the former detaches 
itself from the mucus and other matters and is easily recog- 
nized." When first thrown out on the mucous membrane of 
the pharynx and larynx the yellowish exudation is quite fluid, 
but it soon coagulates, and when discharged it is in shreds of 
various sizes and thickness, or complete casts of the larynx 
may be ejected with immediate relief of the symptoms. 
Quite often I have seen membranes of the consistence of the 
upper layer of thick cream, and I have noted membranes as 
dense and firm as kid leather ; sometimes the creamy mem- 
brane comes away mingled with shreds of the denser type. 
Valleix detected the membrane in 26 cases of 51, and Drs. 
Meigs and Pepper write, " Of the 35 cases observed by our- 
selves, it was expelled by vomiting or coughing in 12 ; in 21 
none was ejected, though its presence in each case was 
proved by the character of the symptoms and by its exist- 
ence in the fauces, by autopsy or by the operation of 
tracheotomy ; in one there was expectoration of masses of 
viscid, yellowish fibrin, though none of membrane ; and in 
tone there was no positive evidence of its existence." At 
times a fragment of false membrane is detached, wholly or 
in part, from the laryngeal mucous membrane, and is carried 
below the vocal cords, causing a long-drawn, suffocative 
paroxysm, which may prove fatal unless, by a desperate 
effort, the membrane is dislodged. When the loosened 
membrane is of small size it makes a flapping noise, easily 
recognized by the stethoscope. 

It will be noticed that all the symptoms remit, but are 



PSEUDO-MEMBRANOUS CROUP. 195 

never wholly absent, and the slightest cause, as taking a little 
food or saying a few words, causes an immediate return, with 
increased violence. At first the fever is slight, and in many 
cases it is altogether absent, but in the second stage fever is 
almost invariably present, and in general terms it may be 
said to be high in proportion to the extent and intensity of 
the local inflammation. The pulse, which was full and hard 
during the first stage, and from 110 to 125 to the minute, 
in the second stage is slightly more frequent, rising 20 to 30 
beats during the suffocative paroxysms and falling as much 
during the remissions. If the disease should extend to the 
bronchial tubes, at once the pulse increases in frequency. 
While the disease is, as a rule, marked by remissions in some 
cases, in the words of Professor Wood, it " marches directly 
onward to suffocation almost without paroxysms." The 
suffocative attacks seem an age to the anxious medical 
attendant and still more anxious mother ; in reality they last 
but three to six minutes, rarely a quarter of an hour, and 
they commonly end in a certain relief, marked by a brief 
slumber, but the wheezing inspirations tell of the continued 
presence of a terrible danger. As morning approaches there 
is a longer remission of all the symptoms, even of the loud 
rattle, and a sleep of some length is obtained ; but I am not 
prepared to say with Baehr, " in the morning the little 
patient may feel quite well, except perhaps a little weak and 
languid." That is not my experience, for next day I always 
have very sick patients on hand, in whom a mere remission 
of the disease is present, thus affording precious time for 
further treatment. I grant that croup, as a general rule, 
shows a decided remission in the morning, which sometimes 
almost amounts to an intermission ; certainly the respiration 
is more free and the voice returns, and the fever, too, abates, 
and even the cough is less frequent. But the cough has a 
reedy, piping tone which suggests trouble during the coming 
night, the fever shows that the local inflammation still 
exists, and on examining the pharynx it will be found that in 
a majority of cases pearly islands of false membrane tell of 



196 PSEUDO-MEMBRANOUS CROUP. 

still greater deposits in the larynx. Note that this remission 
is the time for successful treatment. Neither do I agree with 
my distinguished German colleague when he writes : " Up 
to this period (the morning after the night in which the fully 
developed disease appeared), croup resembles an ordinary 
attack of laryngitis so perfectly that it is often impossible to 
distinguish one from the other. This uncertainty and 
vagueness of the symptoms may continue during the second 
and even third night, although the croupy character of the 
attack becomes more and more marked as the disease pro- 
gresses on its course." So far as my experience goes, the 
characteristics of this truly frightful disease are present from 
the time of its first outbreak. Only in comparatively rare 
cases can there be any doubt as to the diagnosis on the 
morning after the attack. One little-noted characteristic 
of the disease is apt to throw the practitioner off his guard, 
that is, that the first paroxysm is often followed by a 
remission so nearly perfect that the most careful ausculta- 
tion is needed to prove the existence of the disease. 

Let us pause here and consider the mechanism of the 
disease, for much depends on a knowledge of it. The 
dyspnoea of croup has, from the first, fixed the attention of 
medical observers, and the old view, once universally held, 
is that it is mechanically produced by the croupous mem- 
branes. Later, the idea of spasm of the glottis gained a 
number of adherents, and Billard and other French writers 
still maintain this hypothesis. Another explanation given 
by Bretonneau, and still held by a small number of practi- 
tioners, is that the dyspnoea is caused by the difficulty with 
which the secretions of the bronchi are forced through 
the glottis narrowed by the deposit of false membranes. 
Rokitansky maintains that "the infiltrated, pale, relaxed 
muscular tissue, in croupous inflammation, is stricken with 
palsy," and he looks upon dyspnoea as a result of the 
paralysis of the laryngeal muscles. These views of Roki- 
tansky are supported by Schlautmann and von Niemeyer, 
and the latter points out that section of the par-vagum nerve 



PSEUDO-MEMBRANOUS CROUP. I97 

in young animals furnishes absolute proof that paralysis of 
the muscles of the larynx produces dyspncea ; nay, the 
dyspnoea arising in consequence of this experiment bears so 
strong a resemblance to croupous dyspncea, is attended by 
such similar long-drawn, whistling inspiratory efforts, and 
other signs, that the similarity of the two conditions must 
strike the most indifferent beholder." Dr. von Niemeyer 
further remarks that in paralysis of the laryngeal muscles 
the inspiration is laborious and prolonged, while the expira- 
tion is free and almost normal, and he sums up his views on 
this interesting topic by stating that paralysis of the laryngeal 
muscles causes laborious and whistling inspirations with free 
expiration, while the narrowing of the glottis by croupous 
membrane is really an interference with both entrance and 
exit of air, hence the difficulty in both inspiration and 
expiration. There is truth in all these apparently discordant 
views, but their supporters have been too one-sided, for any 
intelligent physician who carefully studies a few cases of this 
disease will see that the dyspnoea has three distinct sources 
— mechanical, spasmodic and paralytic — and of these the 
most influential is certainly the mechanical one — the 
narrowing of the larynx by the swelling of its walls and the 
false membrane deposited on its surfaces. Paralysis of the 
laryngeal muscles is present in many cases, and certainly 
spasm of the glottis is common, and these three factors make 
up the dyspncea of pseudo-membranous croup. 

The vocal cords swell and thicken, and they are coated 
with a very delicate false membrane, which gradually 
increases in thickness, and, as a result of these morbid 
changes, the vibratility of the cords is altered. Hence the 
characteristic hoarseness. The older practitioners considered 
that the cough was caused by spasm of the glottis, but it is 
now known that the tone of the cough, like the changes in 
the voice, depends on the same swelling and thickening of 
the vocal cords, resulting from the deposit upon them of the 
characteristic false membrane. As a result, the cords are 
greatly less mobile than in health, and hence the voice is, 



I98 PSEUDO-MEMBRANOUS CROUP. 

from the first, rough and harsh, then crowing and barking, 
and finally, it is suppressed. Quite likely, a partial paralysis 
of the muscles which open the glottis — the crico-arytaenoidei 
postici — is an essential ingredient in the changes in the voice 
and in the tone of the cough. 

As a rule, then, the patient on the morning after the first 
nocturnal attack has some degree of hoarseness of the voice, 
with a hoarse and resonant cough, and I have noted that a 
free and frequent cough gives better promise of recovery 
than an infrequent or suppressed one. The pulse will be 
fuller and more frequent than natural, and the temperature 
will be a degree and a half, or so, higher than the normal. 
As night approaches the breathing becomes loud, difficult 
and wheezing, the cough is of the same character as on the 
previous night, only less sonorous and more distressing, and 
already the patient feels the sensation of impending suffo- 
cation. When the paroxysm of cough approaches the little 
patient rises in his bed, clutches at the mother with a 
dreadful energy, or falls down as if convulsed. But little 
expectoration attends the cough, at best a small amount of 
glairy mucus, sometimes blood-streaked, is discharged. The 
pulse is hard and frequent, though the temperature is some- 
what lower than on the previous night. The face is flushed 
and swollen, and the voice, hoarse at the beginning of the 
night, is often almost inaudible by morning. At the very 
latest the disease is at its height by the close of the third 
day, but often long before that time the intensity of the 
attack has developed the third stage — the stage of asphyxia, 
or rather of threatening suffocation. As this stage 
approaches, the remissions between the paroxysms grow 
shorter and shorter, till the paroxysm is continuous or 
nearly so. The voice is whispering or entirely suppressed ; 
the cough is dry, stifled, infrequent or entirely absent ; the 
respiration is slower and more convulsive from the mechanical 
obstacle to the entrance of air ; and both inspiration and 
expiration are marked by a loud stertorous noise. The child 
is drowsy, and from that ominous slumber it starts in terror 



PSEUDO-MEMBRANOUS CROUP. 1 99 

and grasps at the poor throat. The cool skin is now covered 
by clammy sweat ; the pulse is too rapid and too weak to 
be counted ; the respiration is so superficial tHat the dyspnoea 
is scarcely noticeable, and the loud stridor is no longer 
present ; at each inspiration the larynx is drawn downwards 
towards the sternum ; at times a desperate rally is made and 
the child struggles hard for breath, but the face becomes 
cyanotic, the extremities cold, and death takes place amid 
coma or convulsions, which sometimes strikingly resemble 
those of spasm of the glottis. The closing symptoms are 
caused by the overloading of the blood with carbonic acid, 
as much as 3.27 per cent, has been found in the expired air. 
When a favorable change takes place it is usually before 
the appearance of the third stage, for a very small number of 
these recover. Usually a discharge of false membrane is 
one of the first signs of amendment, and this discharge is 
sometimes preceded by a sound in the larynx as of loosened 
membrane flapping to and fro with the respiratory movements. 
Generally the expectorated matter is simply tough, and 
whitish shreds mingled with muco-pus — only rarely is a 
cylindrical cast of the affected parts ejected. Bsehr remarks 
that when a cylindrical cast is thrown off, it is not safe to 
regard the danger as entirely over until at least two days 
have elapsed without any trace of a renewed exudation 
having been perceived. The cough becomes milder, the 
breathing easier, the larynx clearer, the fever ceases, the skin 
becomes moist and soft, and slowly but surely the child 
enters upon convalescence. The amendment may be sudden 
or gradual, and the writer has observed that a sudden 
amendment is more likely to be followed by a relapse than a 
gradual one. Dr. West thus describes a striking phase of 
the malady : " The mitigation of the disease may be accom- 
panied by great drowsiness, which, however, does not excite 
alarm, since it is very naturally attributed to the exhaustion 
produced partly by the disease, partly by the remedies. 
During sleep the respiration is deep and tranquil, like that of 
a person in a sound slumber ; it is, indeed, attended by a 



200 PSEUDO-MEMBRANOUS CROUP. 

kind of wheeze, but presents little of the croupy stridor ; and 
when awake the child is quite sensible, and even cheerful. 
After a time, however, it becomes difficult thoroughly to rouse 
him ; his pulse grows more rapid ; the moisture on his skin 
changes almost imperceptibly to a cold, clammy sweat, and 
convulsive twitchings of the angles of the mouth occasionally 
disturb the repose of the features. Silently, but surely, the 
exudation has been making progress, and when the alarm is 
taken it is too late ; the stupor deepens and the child dies 
comatose, or rouses, only to spend its last hours in the vain 
struggle for breath, and embittered by all the painful 
circumstances which ordinarily attend the suffocative stage 
of croup." 

At times, the course of this disease is extremely rapid. 
Much depends on the vitality of the child and a good 
deal upon its docility. In cases where the remissions are 
completely absent, the disease marches on to a fatal termi- 
nation in from twenty to thirty-six hours. I attended one 
fine boy, seen after an illness of only eight hours, who died 
at the close of the eighteenth hour; Vogel says that the 
shortest time he has known, from the invasion of the malady* 
till death, was twenty-four hours, and Dewees has seen it 
run its course in a few hours. Generally, the disease lasts 
from three to five days and Dr. Copland has noted that a 
fatal issue is most common on the fourth day. Dr. Craigie 
says that it is never protracted beyond the eleventh day, 
but Steiner has seen in a child, five years of age, false 
membranes upon the bronchial mucous membrane even 
forty-nine days after tracheotomy, and he is certain that 
exceptionally the disease may run three, four or more weeks. 
He adds, " the longest duration is in the ascending croup." 
Drs. Meigs and Pepper's cases lasted from three to fourteen 
days, and Vogel's longest case died after eight days illness. 

No very large number of thermometric observations have 
been made, and they all confirm the remark of Wunderlich, 
that in no other diseases has the temperature so little signifi- 
cance as it has in croupous and diphtheritic affections. 



PSEUDO-MEMBRANOUS CROUP. 201 

During the incipient stage of the disease, the thermometer* 
shows a temperature varying from 99 to 100° ; on the night 
of the outbreak it may be 102 , rising to 103 or so during 
the paroxysms of dyspnoea, and falling with their departure. 
During the next day the temperature is ioo° to 101 — the 
higher the temperature the more severe the attack during 
the approaching night. But during that second night the 
temperature rarely equals that of the first, and it continues 
to decline unless bronchial or pulmonary complications 
appear, when it may rise to 104 , 105 , or even 106 in 
exceptional cases. I have attended a number of cases in 
which the temperature never rose above 101 , and then I 
had reason to remember the warning of Wunderlich, 
" moderate or even normal temperatures do not give the 
slightest guarantee for a favorable termination." Dr. Squire 
remarks that "a high temperature at the very outset may 
point to one of the exanthemata, its persistence to diph- 
theria." 

The larynx is the seat of pseudo-membranous croup, but 
the larynx is very rarely the only organ affected, the inflam- 
matory irritation usually passing down the trachea and bron- 
chial tubes, even extending to the bronchioles. The older 
writers divide croup into "descending" and "ascending," 
but for many years there has been a strong disposition to 
question the existence of the ascending croup, and many 
physicians in large practice among children have never seen 
a case. Steiner, however, has attended four well-marked 
cases of ascending croup, " In each case the disease began 
with slight febrile symptoms, more or less cough of a painful 
character, and dyspnoea. After from four to six days, while 
the voice was still completely sonorous and without any 
indication whatever of laryngeal obstruction, croupous mem- 
branes were expectorated. Towards the end of the first 
week, and in two of the cases on the fourteenth day — the 
fever still continuing — hoarseness occurred, followed by 
laryngeal stenosis in its full intensity, and, shortly before 
death, by the deposit of false membrane upon the faucial 



202 • PSEUDO-MEMBRANOUS CROUP. 

mucous membrane. In each case the disease was ascribed 
to a severe chill ; three died, and one, a girl five years of 
age, recovered." He adds, " rare as such cases certainly are, 
their occurrence is unquestionable." 

Trousseau says that "the admirable diagnostic methods — 
auscultation and percussion — given by Laennec to the pro- 
fession for the general good, and of which no one is allowed 
to be ignorant, are in our hands what the telescope and 
magnifying-glass are in the hands of the astronomers and the 
naturalist, instruments intermediary between external objects 
and the mind," and it is precisely in the laryngeal diseases of 
children that the stethoscope is too much neglected. I have 
found Cammann's stethoscope, especially the single one, 
immeasurably superior to the old instrument, stigmatized by 
Abernethy as being "a piece of wood with a patient at one 
end and a fool at the other." Especially in croup has it 
served a good turn, though it is not an infallible means of 
diagnosis, for Dr. West says that he noticed on one occasion 
those changes in the tracheal sound which are supposed to 
indicate the presence of a very extensive deposit of false 
membrane, although no false membrane was either expec- 
torated during the patient's lifetime, or discovered in the 
inflamed larynx or trachea after death. He adds " we must 
conclude, therefore, that the changes in the tracheal sound 
do not afford absolutely certain evidence of the existence of 
false membrane, and that still less can they be regarded as 
safe criterions of its extent." At the commencement of the 
disease, laryngeal auscultation simply reveals the character- 
istic stridor, though the air enters easily, and when false 
membrane forms, the sound in the larynx and trachea usually 
becomes less stridulous and more sibilant, though, as already 
remarked, there are exceptions to this rule. Barth and 
Rogers state that when false membrane exists, tremblotement 
— a trembling, vibratory murmur — is present, and that the 
extension of this sound downward demonstrates the exten- 
sion of the disease. Unfortunately, the tremblotement caused 
by the presence of mucus in catarrhal croup cannot be 



PSEUDO-MEMBRANOUS CROUP. 203 

distinguished from the same sound caused by the false 
membrane of the more malignant disease. In all cases the 
information derived from auscultation must be compared with 
the vital symptoms present, and the course of the disease 
must be carefully investigated. 

During the first stage the inspiratory sound is prolonged 
into a harsh and prolonged stridor ; the expiratory sound is 
also prolonged and harsh, but low in pitch, while the 
weakened respiratory murmur is effectually masked by the 
shrill, laryngeal stridor. Still, a certain well-defined mucous 
rhoncus is heard over the larger bronchial tubes, especially 
at the moment when the child makes a very deep inspira- 
tion. No dullness on percussion is present, and the entire 
respiratory movements are notably deficient, even at this 
early stage, and the walls of the chest are never fully 
expanded. During the second stage the sibilant inspiration 
is distinctly heard during sleep, and especially on waking, 
but it has lost the loudness and the persistence which 
marked it during the first stage. Lastly, during the final 
stage of rapidly advancing apncea the characteristic tracheal 
sound is audible all over the trachea during expiration. Dr. 
Hartshorne remarks that a mucous rale, sufficiently tremu- 
lous to be audible without the stethoscope, is usually a very 
favorable sign, as it almost invariably indicates that the 
mucous follicles are throwing out their secretion between 
the mucous membrane and the false membrane — a process 
on which the cure at this late stage greatly depends. 

The laryngoscope can hardly be used with croup patients. 
Even Steiner, with all his skill, is forced to acknowledge that 
it is " almost impossible." Munch gives us the following 
description of his laryngoscopic examination of a boy of ten 
years suffering from croup : " The mucous membrane of 
the larynx was much reddened ; a marked membranous 
deposit covered the aryteno-epiglottidean ligaments, and still 
more copiously the vocal cords ; the glottis was narrowed, 
partly by the deposit on the vocal cords and partly by the 
paresis of the dilator muscles — the posterior crico-arytenoid. 



204 PSEUDO-MEMBRANOUS CROUP. 

Later the whole larynx appeared to be covered with 
membrane ; at the same time it was noticed that the edges 
of the vocal cords were apparently agglutinated to each 
other at various points by a layer of fluid exudation. 
Subsequently the deposit disappeared under the continued 
use of caustics, but was renewed daily, until finally only a 
thin, gauzy membrane was noticed, which returned again 
and again with great obstinacy, especially upon the vocal 
cords. The vocal cords ultimately resumed their function, 
and manifested considerable vitality, even while some of 
the membrane remained. By the sixteenth or eighteenth 
day the normal white color of the cords was restored, and 
here and there a reddish streak was all that could be 
noticed." 

Wherein lies the difference between the ordinary inflamma- 
tion of mucous membrane and the exudative form of inflam- 
mation ? Why is it that one child has, after exposure to 
cold, a simple catarrhal croup, while another, after the same 
exposure, has pseudo-membranous croup ? Dr. Searle of 
Brooklyn, remarks, " wherever the distinction may lie 
pathologically, the fact is certain," and I shall endeavor, as 
correctly as may be, to define the condition which lies behind, 
not only the symptoms, but behind the proximate cause 
which gives rise to the symptoms. 

There is, then, an increased proportion of fibrin, or of 
fibro-albuminous matter in the blood, and this is considered 
by Dr. Cheyne to be analogous to the exudation of the 
inflamed pleura or peritoneum. This fibrinous material has 
a kind of inherent tendency to organization, and this imper- 
fect textural development appears to set in with the process 
of coagulation. " Examined with the microscope, they 
present a laminated basement, and one splitting into fibres, 
flattened or roundish, rough and firm, or resembling organic 
muscular fibres ; or else, a membranous basement invested 
with delicate, wavy fibres, upon which, among elementary 
granules, are seen numerous round, black-edged nuclei, 
sometimes rod-shaped, or drawn out into fibres, and again, 



PSEUDO-MEMBRANOUS CROUP. 205 

more especially in the moisture poured out, dull, round or 
oval nuclei, and analogous cells." (Rokitansky.) This first 
variety* of pseudo-membrane is a tough, elastic, polished 
membrane, quite similar to serous membrane in appearance, 
and very like moist kid leather. At other times the fibrinoid 
is of a dullish white color inclining to yellow, and including 
blood-serum and blood-corpuscles, sufficient to give a reddish 
hue in places. " Microscopically examined, the coagulum 
presents a stratiform or fibro-laminated basement, or else a 
faintly striated membrane, both being, however, opaque, 
owing to delicate granulation. Upon this, as also in the 
serum, are seen a vast number of nucleus-like formations of 
developed, dull, granulated nuclei, and of similar more or 
less developed cells. Frequently the coagulum appears to 
consist altogether of the two last-mentioned elements, with 
a proportion of granulated structure." (Rokitansky.) Again, 
the fibrinoid may be pus-like, of a greenish-yellow hue, with 
little tendency to organization, and but little adhesive power. 
These three varieties rarely occur singly and alone, but 
they are intermingled in varying proportions. The first 
mentioned is the most dangerous, as it approaches the nearest 
to organization ; and the last mentioned is analogous to the 
matter of pyaemia, for it includes pus-nuclei and pus-cells in 
its meshes. The difference between these varities of fibrinoid 
can be readily detected with the naked eye. 

When the mucous membrane of the larynx becomes the 
seat of inflammation or of congestion — for there can be little 
doubt that in croup the primary morbid change is often 
congestion — this fibrinoid or fibro-albuminous matter exudes 
from the distended capillaries, a«id the change of temper- 
ature and the passage of air over it aiding its inherent 
tendency to imperfect organization, it is soon formed into a 
false membrane. As the disease advances, the mucous 
follicles secrete a copious muco-purulent fluid which is 
poured out between the mucous membrane and the false 
membrane, loosening the latter, so that there is a certain 
tendency toward recovery even in the most severe forms of 



206 PSEUDO-MEMBRANOUS CROUP. 

true croup. This congestive or inflammatory action, with 
its accompanying exudation, may go on undetected for some 
little time till the engorgement becomes so great as'to inter- 
fere with the passage of air through the glottis, ortill the more 
or less violent laryngeal spasm directs attention to it. The 
writer is strongly of the opinion that while simple spasmodic 
croup, almost destitute of inflammatory action, stands at 
one end of the scale of morbid action, at the other extremity 
is pseudo-membranous croup, which may be almost wholly 
destitute of laryngeal spasm ; that though well-marked 
typical cases exist, which can be readily diagnosed, yet in 
the middle of the scale we find it extremely difficult to 
decide as to the presence or absence of false membrane ; and, 
lastly, that a case which apparently commences as spasmodic 
croup, may, under certain conditions, take on inflammatory 
action with its attendant exudation. The practical lesson is 
to prescribe for even mild cases with care, and constantly to 
keep in view the possibility of the occurrence of the much 
dreaded pseudo-membrane. 

Dr. Squire asserts that " intense redness of the mucous 
membrane is persistent after death," but even when the 
redness, as observed by the laryngoscope, has been intensely 
bright, at the post-mortem examination the hyperemia may 
have entirely disappeared or be scarcely noticeable. Swelling 
is rarely found, as it, too, disappears with the extinction of 
life, though sometimes the upper orifice of the larynx is 
diminished by the swollen aryteno-epiglottidean folds. Dr. 
Craigie asserts that croupous inflammation is but seldom 
observed to affect the laryngeal mucous membrane, and says 
that when it does so, it is to be viewed as a complication 
not essential to genuine croup ; while, on the other hand, 
Guersant says that the characteristic membrane is never 
entirely absent from the larynx. Here Dr. Craigie is unques- 
tionably in error, for the larynx is always affected in croup, 
though, as Rindfleisch remarks, a croupous inflammation, 
confined throughout its entire course to the larynx, is of rare 
occurrence. 



PSEUDO-MEMBRANOUS CROUP. 20J 

In general terms it may be said that in two-thirds of all 
the cases the disease is limited to the larynx and trachea, 
while in the remaining third the inflammatory irritation 
extends to the bronchi ; though it does not follow that false 
membrane is formed there. " The implication of the trachea 
and bronchi is, at least with us, very common ; in fifty-five 
autopsies of children I found that in thirty-one the croup 
had extended to the larynx, trachea and bronchi, with casts 
even in the smaller tubes ; in nineteen the false membranes 
were limited to the larynx and trachea with purulent or 
muco-purulent secretion on the mucous membrane of the 
bronchi, especially those of the first and second order ; in 
the other jwe cases croupous deposits were present only in 
the throat and larynx, with muco-pus in the trachea and 
bronchi. It is to be particularly noticed that in all these 
cases false membrane was demonstrated in the laryngeal 
cavity, and it is safe to say that the absence of exudation, to 
which some are so ready to appeal, is unquestionably the 
very rare exception "' (Steiner). Again, it may be confined 
to the glottis and it may line the entire larynx, dipping into 
the ventricles so as to form an entire cast of the organ ; in 
very severe cases it extends to the minutest ramifications of 
the bronchial tubes, and this seems to be more common on 
this continent than in Great Britain. Professor Wood has 
seen a case in which the false membrane lined the upper 
portion of the bronchial tubes, the entire larynx and trachea 
and the pharynx as low as the upper part of the oesophagus. 
But the favorite situation of the false membrane is on the 
vocal cords, and, as a general rule, the coating is thick in 
proportion to the duration and severity of the attack. Dr. 
Cheyne compares the tubes of false membranes from the 
bronchial tubes to macaroni boiled in milk, and, in curious 
anticipation of Dr. Craigie, he says that in none of the cases 
seen by him was membranous exudation observed on the 
laryngeal mucous membrane, adding, that if the inflamma- 
tion extended to this part, it was only slight, and its effects 
were seen in a little puriform fluid on the membrane of the 
cricoid or thyroid cartilages. 



208 PSEUDO-MEMBRANOUS CROUP. 

Sometimes the false membrane adheres closely to the 
mucous membrane, but it is generally more or less loosened 
from the action of the muco-purulent fluid already mentioned, 
and this loosening is, in the words of Rindfleisch, " a property 
on which all our therapeutic measures, inadequate as they are, 
repose." After the first membrane is thrown off, a second 
succeeds it, and then a third, till death takes place or 
recovery ensues from the false membrane ceasing to form, 
and when this takes place it is found that the mucous 
membrane is but little injured, in fact it is often quite 
normal. There are great differences in the thickness and 
consistence of the false membrane ; it is sometimes of a 
gauze-like tenuity, while at other times it is one or two lines 
in thickness, the usual thickness being about half a line ; as 
already mentioned it may be like the viscid layer which 
forms on the surface of a bowl of cream, and it may be a 
tough, compact, leather-like fibrin resembling a fragment of 
wet kid glove. Almost invariably, the edges of the 
membrane are thinner and softer than the more central 
portions, and the side in contact with the mucous membrane 
is softer than the side exposed to the air. When it extends 
to the bronchial tubes, Rokitansky remarks that the tubular 
exudations from the larger bronchi present a calibre inversely 
proportional to their thickness, and those thrown off from 
the finer ramifications occur in solid cylinders. Professor 
Wood remarks that in the larynx it is said to be less firm 
than in the trachea ; while Professor Gross asserts that it is 
generally much stronger, more tenacious, and more firmly 
adherent in the larynx than in the trachea and bronchial 
tubes. " The characteristic feature in the morbid anatomy 
of laryngeal croup is due to the fact that the mucous lining 
of the larynx agrees in its structure, partly with that of the 
pharynx, partly with that of the trachea. Both surfaces of 
the epiglottis, and the true vocal cords, are coated with a 
laminated pavement-epithelium, which is not marked off 
from the connective tissue by any homogeneous basement- 
membrane. Hence, the false membranes adhere more firmly 



PSEUDO-MEMBRANOUS CROUP. 20O, 

to these than to any other points in the interior of the 
larynx. How often do we find, in making a post-mortem 
examination, that the tracheal false membrane', continuous 
with that of the laryngeal funnel, is quite loose as far up as 
the rima glottidis, where it is firmly attached ; and we feel 
sure that its spontaneous detachment at this point would 
have required a very long time for its accomplishment." 
(Rindfleisch.) The color of the denser membrane is of a 
pearly, grayish white, while the more diffluent membrane is 
of a yellowish white. 

Small quantities of carbonate of soda and phosphate of 
lime have been detected in the false membrane, and it is 
soluble in acetic acid and alkaline solutions, especially in 
lime water , in short, in all its chemical relations it closely 
resembles coagulated fibrin. Examined microscopically, 
according to Steiner, it is found to be composed of 
amorphous or fibrillated fibrin, in which numerous young 
cells are entangled. Squire says that it is not simply fibrin, 
but that " it consists of effused lymph, in which the presence 
of albumen can always be chemically demonstrated ; 
microscopically it is a mass of cystoid corpuscles." 

Is the false membrane susceptible of organization ? 
Generally speaking, it gives no indication of such an attri- 
bute, and yet Rokitansky thinks that an effort at organiza- 
tion occasionally takes place. " The surface next to the 
mucous membrane is frequently marked with red streaks and 
dots, consisting in part of blood adhering to the surface, and 
in part, as found on closer examination, of straight or 
tortuous vessels, or of small, roundish, extravasations, from 
which currents of blood are seen to emerge in an arborescent 
and radiating form." Professor Hasse remarks that the 
effort at assimilation is, in some instances, very perceptible 
in the appearance of stellated ecchymoses and bloody streaks 
on the surface of the false membrane, facing the mucous 
membrane. 

The mucous membrane subjacent to the false membrane 
seldom presents the appearance of severe inflammation, 



210 PSEUD0- MEMBRANOUS CROUP. 

though it may be red, purple, or even blackish in color, and 
these tints are in spots or patches, which are sometimes 
arranged in irregular stripes. The mucous membrane is 
sometimes, but rarely, in a state of gelatinous softening, and 
thickening is still more rare. West has observed ulceration 
in one acute case, but frequently in cases of secondary 
croup, probably diphtheria. But, on the whole, the mucous 
membrane producing the croupous membrane remains, as 
Squire remarks, ''singularly free from pathological injury." 
At an advanced period of the disease the redness may 
disappear, when the mucous membrane regains its usual pale 
color. The trachea and bronchial tubes are usually red- 
dened, even though the disease has not extended to them, 
and the bronchial tubes contain a yellowish, puriform fluid, 
which has doubtless passed downward from the seat of 
morbid action. A certain degree of pulmonary congestion 
is an almost inevitable result of croup, and the same may be 
said of the vesicular emphysema, which results from the 
extraordinary efforts to breathe, which sometimes brings on 
laceration of the pulmonary vesicles. The same desperate 
respiratory efforts often cause congestion of the brain and 
even effusion of serum into the ventricles. 

To those physicians who believe that there is but one 
kind of croup, clearly but little diagnosis is necessary. Thus 
the celebrated Dr. Dewees speaks of "a distinct species of 
croup, namely : the spasmodic, a kind we have never 
witnessed," though Drs. Meigs and Pepper, who practice in 
the same city that was honored by the residence of 
Dr. Dewees, declare that they meet with six cases of 
spasmodic croup for one of pseudo-membranous. Again, 
Dr. Robert C. R. Jordan, Professor of Diseases of Children, 
Queen's College, Birmingham, England, writes as follows : 
" In all my own early teaching it was strongly impressed 
upon me that "croup" was always a membraneous exudation 
in the larynx or trachea, that it became to my mind a great 
difficulty to throw off the trammels of this old*belief, and it 
was long before I could feel fully persuaded of what I now 



PSEUDO-MEMBRANOUS CROUP. 211 

know to be the truth — namely, that the majority of the 
cases usually called by this name have no false membrane 
formed at all, but that their essential nature is an inflamma- 
tion of the mucous membrane of the larynx and trachea, 
accompanied with secretion of tenacious mucus, and also 
considerable swelling caused by effusion into their sub- 
mucous areolar tissue. They are, in fact, catarrhal inflam- 
mations of the larynx and trachea. All other cases where 
exudation is really present are diphtheria ; and it is in this 
sense and with this definition only that we can regard croup 
and diphtheria as two distinct diseases." 

The diagnosis between pseudo-membranous croup and 
catarrhal croup will be found in ChapterV, that between croup 
and spasm of the glottis in Chapter IV. It remains, then, 
to give the diagnosis between spasmodic croup and pseudo- 
membranous croup, for a diagnosis can certainly be made in 
spite of the confident assertion of Dr. Maunsell that " there 
are no means of distinguishing between the two affections 
(if two distinct affections exist), beyond # the degree of 
violence of the symptoms." 

The attack of spasmodic croup, then is, as a general rule, 
sudden and startling, while the invasion of pseudo-membra- 
nous croup is insidious and creeping. In spasmodic croup 
the voice is hoarse but never whispering, save during the 
height of the attack, while in pseudo-membranous croup, 
the voice, at first hoarse, soon becomes whispering, and 
finally is entirely lost. The cough of spasmodic croup is 
rough and hoarse throughout, while in pseudo-membranous 
croup the cough is rough and hoarse at first, infrequent 
further on, and finally is quite suppressed. In spasmodic 
croup the suffocative attacks generally occur at the begin- 
ning of the disease, in pseudo-membranous croup they come 
on at an advanced stage. In spasmodic croup great 
dyspnoea is very rare and it never persists, but in pseudo- 
membranous croup dyspnoea is an essential feature of, the 
disease. The respiration of spasmodic croup is stridulous 
and difficult only during the paroxysm, but almost natural 



212 PSEUDO-MEMBRANOUS CROUP. 

in the interval, while in pseudo-membranous croup the 
respiration, at first almost normal, becomes very nearly 
permanently stridulous. In spasmodic croup the fauces are 
quite clean or a slight redness may be present, but in pseudo- 
membranous croup a fibrinous exudation is quite common. 
In spasmodic croup the fever is very slight and may be 
altogether absent, and it may only appear during the 
paroxysm, while in pseudo-membranous croup the fever is 
quite high. . After the paroxysm of spasmodic croup the 
child is quite well and the fever departs, but after the first 
paroxysm of pseudo-membranous croup the child is quite ill, 
with high fever, stridulous breathing and hoarse cough. If 
the paroxysm of spasmodic croup returns the second night 
it is less severe than it was the previous night, but the 
second nocturnal paroxysm of pseudo-membranous croup 
has increased dyspnoea and threatening suffocation. Spas- 
modic croup rarely lasts more than three days, and good 
treatment reduces this to thirty-six or forty-eight hours, and 
it is not followed by hoarseness, while pseudo-membranous 
croup is rarely of shorter duration than five or six days, 
and hoarseness is apt to continue for two or three weeks. 
A child may have repeated attacks of spasmodic croup, but, 
as a general rule, true croup does not recur. Lastly, 
spasmodic croup is hardly ever fatal, while pseudo-membra- 
nous croup, in spite of the best treatment, is frequently 
fatal. 

Pseudo-membranous croup is always a serious disease, but 
the homoeopathic physician need not assent to Vogel's 
maxim, " the prognosis in well-declared croup may be set down 
as fatal!' or even to Sir Thomas Watson's well-known 
dictum, "the prognosis can never be better than doubtful" 
though that, after all, is merely the legitimate result of a 
treatment comprehending blood-letting, tartarized antimony 
and caloi7tel, said by the last-mentioned eminent authority to 
be ''the remedies that most require consideration." Almost 
all physicians — especially those of European education and 
experience — will assure you that, under any circumstances, a 



PSEUDO-MEMBRANOUS CROUP. 213 

majority must die, but with a thorough knowledge of the 
pathology of the disease and of the admirable therapeutic 
agents which homoeopath}' places at our disposal, the writer 
believes that a majority will live. 

Guersant says that it is ''generally fatal," adding that it is 
scarcely possible to save two in ten, while Rilliet and Barthez 
state that "its common termination is in death." Steiner 
thinks that the prognosis is ''almost always dismal, a fatal 
result being almost the rule, for in tracheotomy alone there 
seems any chance of recovery." Felix von Niemeyer 
considers it " one of the most formidable of diseases." and 
Squire thinks that "the slightest cases of croup furnish grave 
cause for anxiety." Maunsell is almost the only writer who 
takes a really cheerful view of the matter, and he affirms 
that "it is remarkably within the control of art" — very true 
of spasmodic croup, but not quite so true of pseudo- 
membranous croup. Dr. Squire speaks of " the hopeful 
conjecture of Dr. Wood, of Philadelphia, that one case in 
fifty only is fatal," but Dr. Squire overlooks the fact that the 
great Philadelphia!! is speaking of the " ordinary croup of 
this country," which is catarrhal and spasmodic in its nature. 
Meigs and Pepper lost sixteen out of thirty-five cases, 
though they have attended two hundred cases of spasmodic 
croup without a death. 

The danger is great in proportion to the youth of the 
patient. A child a year old has less chance than one of five 
years, and, as already stated, the disease is more fatal in 
boys than in girls. Yogel's experience is that children who 
have passed their seventh year may survive attacks of 
croupous laryngitis of the utmost intensity. 

Very much depends upon the stage of the disease at 
which the patient comes under treatment, and quite as much 
depends upon the physician possessing an accurate knowl- 
edge of the disease before him. If no efficient treatment is 
adopted till the disease is fully developed and the false 
membrane formed, the prospect of cure is much diminished ; 
but if, on the other hand, it is recognized from the 



214 PSEUDO-MEMBRANOUS CROUP. 

commencement, and skilful medical attendance is joined to 
careful nursing, the chances of recovery are better. Pneu- 
monia aggravates the danger, and when the bronchi become 
implicated in the disease, the prognosis is very grave, though 
it is well to remember that in bronchial croup the membrane 
is less firmly adherent than in the laryngeal and tracheal 
forms. Although the general symptoms should be duly 
weighed, especial attention should be paid to the local 
symptoms, and to the frequency of the paroxysms. It is 
unfavorable if the stridulous sound is heard both in inspira- 
tion and expiration, and complete extinction of the voice 
and suppression of the cough are most ominous signs. Sir 
Thomas Watson remarks, " we begin to despair when the 
lips are turning blue, the skin is losing its heat, the pulse is 
already feeble and intermitting, and the little patient is 
drowsy or comatose." On the other hand, the favorable 
signs are diminution of the stridulous respiration ; return of 
the voice, even though it be hoarse ; looseness of the cough 
with expectoration of muco-purulent matter mingled with 
fragments of false membrane ; and decrease of the dyspnoea. 
Dr. Meadows observes that ''sometimes just as the active 
signs of the attack are subsiding, a relapse takes place,, and 
the condition becomes a much more alarming one ; this 
tendency to relapse should make our prognosis guarded for 
at least two or three weeks, and particularly in weak, delicate 
and irritable children." In like manner, Dr. Charles West 
says that much caution must be exercised in drawing a 
favorable conclusion from a diminution of the severity of the 
symptoms, until such improvement has continued for twenty- 
four hours at least ; and I can most cordially endorse Dr. J. 
F. Meigs' axiom, " the case should not be abandoned as 
hopeless until life is actually extinct." Very cheering, too, 
are the words of Maunsell, " children have recovered from 
the most hopeless condition, and we should never despair of 
a sick child." 

Children who show any tendency to croup should not go 
out of doors when cold east winds are blowing, and when 



PSEUDO-MEMBRANOUS CROUP. 21 5 

such children go out, even in moderately cold weather, they 
should be warmly and comfortably clad, especially about 
the feet and neck. In addition to this precaution the neck 
and chest should be systematically sponged with cold water 
every morning, and in addition, gargles of cold water should 
be used two or three times a day. 

At the first faint hint of croup in the voice, respiration or 
cough, I have seen singularly good results from the application 
of a sponge dipped in hot water — as hot as the child will bear 
— directly over the larynx and trachea. The sponge should 
be well squeezed out, refilled and again applied every two or 
three minutes, for say half an hour. At the same time, 
steps should be taken to secure a warm, moist and uniform 
atmosphere for the little patient, in fact, as Dr. Prosser 
James urged, many years ago, " the patient should be kept, 
as it were, in a vapor bath," and of temperature too, much 
higher than is usual in any sick chamber. The temperature 
should be kept from ?o° to 75°, and I have kept it at 
8o° for two or three days with excellent results. In order to 
accomplish this it will be necessary to make a so-called 
' croup-tent ; around the child's bed, behind that tent a kettle 
of boiling water is placed on a spirit lamp, and the steam 
from the kettle is thrown into the tent by means of a long 
tin spout. But ventilation must be seen to, for fresh air is 
just as much a necessity as warm, moist air, and without 
fresh air the croup-tent would be a positive nuisance. I do 
not recommend the warm bath, believing with Cheyne that 
"the warm bath is a very equivocal remedy." The diet 
should be bland and mucilaginous throughout the illness, 
though well-made beef-tea in small quantities is always in 
place. 

I incline to think that medical men of our school look 
with a less favorable eye on tracheotomy than do their 
brethren of the dominant medical faith. The chief cause 
of this seems to be the great reliance which we justly 
place upon our therapeutic agents, and hence, Baehr, our 
best systematic writer, summing up the resources of the old 



2l6 PSEUDO-MEMBRANOUS CROUP. 

school against true croup, says : " In spite of all these 
appliances, from 70 to 90 per cent, of all undoubted cases of 
membranous croup perish. This result is certainly no 
triumph, nor has tracheotomy increased the chances of 
recovery." 

Home first suggested tracheotomy in his classic work on 
croup, in the year 1765, though he never performed the 
operation. In the year 1792, a London surgeon named 
John Andre secured the honor of the first operation, at all 
events, his is the first recorded case. In 18 18 the celebrated 
Bretonneau revived the operation, but his patient died and 
the same result followed a second attempt six .years later. 
As an epidemic of diphtheria was raging at the time — the 
epidemic, in fact, in which Bretonneau won such imperishable 
laurels — it is highly probable that these were diphtheria 
patients, hence the fatal result, for in the language of Dr. 
A. W. Barclay, " tracheotomy is certainly more adapted to 
this disease (pseudo-membranous croup) than to diphtheria, 
in so far as the attack is local instead of constitutional, is an 
inflammation instead of a blood-poisoning." In 1825, 
Bretonneau again attempted the operation, this time with 
success, and following his lead, Trousseau, for a time, saved 
half his patients, though the average of recoveries seems to 
have been about one-fourth of the whole number of cases. 

The older English practitioners had but little confidence 
in tracheotomy. Cheyne never approved of it, and argued 
against it with a good deal of skill, and he had very great 
weight with the English practitioners almost down to our 
own day. Copland gives a resume of treatment, including 
bleeding, emetics, purgatives, sudorifics, expectorants, anti- 
spasmodics, calomel, blisters and baths, concluding with 
Valentin's famous recommendation, " the application of the 
actual cautery upon each side of the throat, in the most 
severe forms of the disease, when it is at its acme," to which 
the distinguished author of the Dictionary of Practical 
Medicine adds, " there does not seem to be a chance from 
this operation in any case wherein the treatment developed 



PSEUDO-MEMBRANOUS CROUP. 2\J 

above has failed." Certainly, after the patient has been 
subjected to the destructive art of healing as exemplified by- 
such a course of treatment, he would be mOst unlikely to 
possess sufficient vitality for tracheotomy or any other 
operation. The older practitioners on this continent 
sympathized with their English brethren in this matter. 
Dr. Dewees was very strongly opposed to it ; Dr. Physick 
had no confidence in it, and the operation was little used 
till a new generation of practitioners arose who leaned less 
on authority and more on personal experience. 

Greve places the mortality in Sweden at 23 per cent.; 
Trousseau at 50 ; Franquet at 68 ; Bricheteau, who draws a 
sharp line between diphtheritic and true croup, gives the 
mortality from the latter as 69 per cent. Steiner endorses 
the operation, yet he says : " The proportion of recoveries 
is stated by all writers of honesty and diagnostic skill as 
lamentably small. Out of quite a large number of cases 
occurring in my practice, before I had adopted the operation of 
tracheotomy, I saw but three recoveries ; since 1863, however, 
this discouraging rate has been so much improved by the 
employment of tracheotomy that the mortality has, at 
different times, amounted only to sixty, sixty-five and seventy 
per cent." 

French physicians have employed tracheotomy with 
marked success, so much so that one feels morally certain 
that all their patients could not have been blood-poisoned, 
diphtheritic ones, but that many of them must have suffered 
from pseudo-membranous croup, and their success arose from 
the fact that they operated in the early and hopeful stage of 
the disease, while the English, till very lately, seldom 
resorted to it till the case was hopeless. Furthermore, I 
believe that there are cases, not very many it is true, of this 
disease, in which tracheotomy offers the only chance of life — 
I allude to the fondroyante cases, in which the disease 
marches on to a fatal issue, unchecked by the best selected 
remedies. In these cases the only safety, lies in the prompt 
and skillful use of the knife. 



2l8 PSEUDO-MEMBRANOUS CROUP. 

Tracheotomy does not increase the risk of a fatal issue, 
and personally I am almost of opinion that the operation is 
justifiable if only to secure euthanasia. The operation has 
been but little employed by the homoeopathic practitioners 
of this continent? partly because the disease is comparatively 
rare, and partly because, as already remarked, we have a 
thorough knowledge of better remedies. 

In the first stage of pseudo-membranous croup, I consider 
Aconite beyond all question the leading remedy, for it corre- 
sponds not merely to the symptomatic appearances, but it 
combats the very inmost essence of the disease. In addition 
to the indications given in the chapter on spasmodic croup, 
I would add the following, by the venerable and beloved 
Charles Julius Hempel, who may justly be said to have 
stamped the peculiar impress of his mind on the homoeo- 
pathy of this continent: " In Membranous Laryngitis, or 
Croup, Aconite is often sufficient to arrest the inflammatory 
process which is going on in the lining membrane of the 
larynx, or to promote its absorption. More than one 
symptom among the symptoms of Aconite points to its use 
in croup as a specific remedy. Among the Aconite symptoms 
we have hoarseness, croaking voices, feeble voice, complete 
loss of voice, sensitiveness of the larynx to the inspired air 
as if the mucous membrane were deprived of the epithelium, 
sensation as if the sides of the larynx were pressed together. 
These and similar symptoms, together with the dry, hard 
and tearing cough which Aconite excites, and the raw feeling 
in the larynx during the paroxysm of cough, are strikingly 
characteristic indications for the use of Aconite in croup." 

Dr. Elb advances the following views : "Aconite, as a 
medicine corresponding to the local affection and the accom- 
panying fever, must- be a perfectly appropriate remedy, and 
this is corroborated by experience. But as other character- 
istic symptoms are peculiar to croup, such as the deposition 
of the exudation, it is evident that Aconite cannot suffice 
for all cases or stages, and hence that its applicability is 
limited. Experience teaches us that it is of use when 



PSEUDO-MEMBRANOUS CROUP. 219 

inflammation is still present and accompanied by fever, with 
hard, full, frequent pulse, and when there is great anxiety 
and rough respiration. It will accordingly be* chiefly suitable 
for the beginning of the disease, a view in which not only 
all practitioners are agreed, but this is often laid down as the 
sole indication." Ruckert writes, "Aconite, in fine, should 
always be administered in the inflammatory stage ; it thereby 
assists the action of the next remedy indicated." Baehr 
teaches as follows : " If we are called to a case of croup in 
the night, it is not always possible to at once obtain the 
conviction that we are dealing with a case of croup; for 
even the presence of considerable dyspnoea does not always 
imply that the disease before us is croup. In order to meet 
this uncertainty the custom has prevailed for a long time 
already to at once give Aconite in alternation with some 
other remedy. We do not approve of this custom of giving 
remedies in alternation, but make an exception in favor 
of croup on account of the uncertainty in our diagnosis. 
Aconite is excellent in catarrhal, but utterly inefficient in 
membranous croup. If we suspect a case of membranous 
croup, we give Aconite 2, and Iodium 2, in alternation every 
hour." Hughes writes, "Whatever medicine you choose, I 
recommend to alternate it with Aconite. Croup is a neuro- 
phlogosis, and the spasmodic paroxysms need as much help 
as the continuous inflammation." Baehr and Hughes are 
undoubtedly, at the present time, the leading homoeopathic 
writers of their respective countries, and yet in opposition 
to their authority, I would advise Aconite, and all other 
remedies, to be given singly and alone. For many years I 
alternated remedies, and my practice remained destitute of 
a sound experience. At length, in the Fall of 1869, I made 
a tour through the Western States, when I noted that nearly 
all the practitioners who alternated were strongly disposed 
to mix medicines. Finally, the crisis came when a distin- 
guished physician advised me to take equal quantities of 
Leptandrin 1, Podophyllin 1, and Mercurius solubulis 1, 
triturate them together, and give this highly-scientific prepa- 



220 PSEUDO-MEMBRANOUS CROUP. 

ration in fiVe-grain doses three times a day as a panacea for 
" liver complaint." I returned home and never alternated 
more. Since that time I have adhered unswervingly to the 
single remedy, and, while I have had vastly better results, I 
have gradually attained to such an insight into therapeutics 
as I never could while wandering in the quagmire of alter- 
nation. Give but one remedy. Should that cease to be 
indicated select another, but never alternate. ■ 

Ruddock, following in the wake of Hughes, says: " Even 
when another medicine is indicated it is often advisable to 
administer Aconite in alternation to relax the spasm which 
often complicates the disease." 

" A child three years old ; severe croup ; at the point of 
suffocating. Aconite I, one drop in a glass half full of water, 
a teaspoonful every quarter of an hour. After a few doses 
profuse perspiration broke out and the child was saved." 
(Dr. A. Crica.) 

" A fat, healthy child, aged two years, was taken suddenly 
with croup after an exposure to a dry, cold, west wind. 
Face and skin burning hot ; wants to drink constantly ; 
agonized expression ; constant restlessness ; aggravation 
after sleeping. Aconite 200, two doses half an hour apart, 
cured." (Hoyne.) 

In this disease I have confined myself to the use of the 
tincture of the fresh root, or the first and second decimal 
dilutions of the same preparation, from two to five drops in 
a tumblerful of water, a teaspoonful every half hour, or even 
every fifteen minutes. I am aware that I have been cen- 
sured for recommending the use of mother tinctures and low 
dilutions, but I would remark that I am not giving the 
experience of my censors, but my own. Very much more 
important than an adherence to the high potencies is a 
thorough knowledge of pathology and pathological anatomy, 
and a little of the eloquence directed against the low 
dilutions would not be thrown away if it were turned against 
the polypharmacy and alternationism and isopathy which 
threaten to engulf our school. 



PSEUDO-MEMBRANOUS CROUP. 221 

Iodine is a remedy upon which many physicians rely in 
this disease, though Kreussler, an excellent therapeutist, says 
that " he does not recommend it, as our provings upon the 
healthy do not seem to point to Iodine as a remedy for 
croup." It was introduced as a remedy for pseudo-membra- 
nous croup by Koch in 1841, and since that date Spongia 
has lost its position and is now only used in the less danger- 
ous catarrhal and spasmodic croups. Koch reports that he 
gave Iodine alternately with Aconite in thirteen cases of 
croup, all of which he affirms were pseudo-membranous, with 
such success that none died ; but, as a writer in the Neues 
Archiv. points out, " the result does not speak decidedly 
enough in favor of Iodine, for a second remedy, often of 
essential service in croup, was always given in alternation." 
Still, the same writer admits that in a patient affected with 
stenosis of the larynx, Iodine produced the most frightful 
suffocative symptoms and a sound like the most violent 
croup, and he adds that four cases of the cure of croup by 
Iodine are recorded by Tietze in the Neues Archiv., vol. I. 

Both Elb and Bsehr urge us to give Iodine from the very 
inception of the disease. Elb writes : " given at the first 
onslaught of the disease it is calculated to cut short the whole 
malady ; " and Baehr thinks that " there is no reason why a 
medicine that embraces in its pathogenetic series all the 
symptoms of croup, and must therefore be adapted to every 
stage of this disease, should not be given at the very 
commencement of the attack." Elb alternates Iodine with 
Aconite — indeed it seems to be almost impossible to get 
practitioners to confide in one single remedy in this disease 
— and even Baehr, usually a single-remedy man, .apologeti- 
cally says, that " we do not approve of this custom of giving 
remedies in alternation, but make an exception in favor of 
croup on account of the uncertainty in our diagnosis." 
" Like the sudden subsidence of a storm," writes Elb, "so 
wonderfully *quick is the action of this first dose, if the dose 
was not too strong, the anxiety and imminent suffocation 
and whistling cough cease, as if by magic, and the dyspnoea 



222 PSEUDO-MEMBRANOUS GROUT. 

becomes so much diminished that we may safely wait an 
hour before giving a dose of Aconite ; this speedily procures 
a remission of .the fever, with the breaking out of a beneficial 
perspiration ; the danger is generally past in a few hours, 
notwithstanding which pause it is not advisable to leave off 
the medicines too soon, seeing that the disease can only be 
suppressed and kept down by these means ; for which 
reason I continue the use of Iodine and Aconite alternately 
every hour, even during sleep, until the breathing is no 
longer sawing and the cough has become looser, after that 
only every two or three hours ; in this way the transition to 
an ordinary catarrh is effected, and recovery takes place." 
Hempel, in his work on Practice, places most reliance on 
Aconite and Spongia, adding : " If Spongia seems powerless 
and the spasmodic wheezing continues, we must try Iodine." 
Hughes considers Iodine "our chief remedy in true croup," 
and adds that " the medicines between which our choice lies 
are Iodine, Bromine and Kali bichromicum." Meyhoffer 
considers that Iodine is most suitable for sporadic croup 
occurring in previously healthy subjects, when the disease is 
more sthenic in form, and Ruddock that Iodine should be 
preferred to Bromine in scrofulous patients. 

The symptoms indicating this remedy are not very clearly 
marked. Koch speaks in general terms of the great value of 
Iodine in true croup, looking upon it as a kind of panacea, 
but he gives no special indications for its use. Elb gives 
the following excellent indications for this " most efficacious 
and most frequently applicable remedy": 

" I. In cases where there are violent fits of coughing, 
threatening suffocation, with whistling tone and great 
anxiety; hissing, sawing, respiratory sound; painfulness of 
the larynx ; hoarseness and red face, synochal fever ; conse- 
quently at the first appearance of^the disease. 

"2. In cases where there are long continued fits of loose- 
sounding coughing, without great danger of suffocation, 
which affords the patient no relief, with slight painfulness of 
the larynx ; strong sawing and hissing but not whistling 



PSEUDO-MEMBRANOUS CROUP. 223 

respiratory sound ; temperature of the skin not elevated ; 
with frequent, hard, but not full pulse. 

" 3. In cases where there is want of cough, or rare, short, 
loose sounding, but still genuine croupy cough ; with 
constant, but apparently not very troublesome, oppression 
of the chest, and rough, sawing, not whistling, respiratory 
sound ; cold, moist skin ; small, hard, quick pulse. 

"4. In cases where the bronchial ramifications are chiefly 
affected, consequently where there is want of cough, or rare, 
short cough without the croupy tone ; inaudible vesicular 
inspiration ; short, quickened respiration ; loss of voice, with 
weak sawing, rather rattling respiratory sound ; abdom- 
inal inspiration ; painlessness of the larynx and trachea ; 
pale, fallen-in countenance ; cold skin, covered with clammy 
sweat, with weak, small, rapid, and even thready pulse." 

There is roughness in the larynx, also painful pressure and 
stitching in the same organ ; pressure in the larynx and 
pharynx, as if swollen ; pain in the larynx w T ith discharge of 
hardened mucus ; constriction and heat in the larynx ; 
increased secretion of mucus in the trachea; dry, short and 
hacking cough; soreness of the throat and chest when in 
bed, with wheezing in the throat and drawing pains in the 
lungs, corresponding with the beat of the heart ; great 
difficulty in breathing ; tightness of the chest when breathing 
deeply; more violent and quicker beat of the heart, with 
smaller and more rapid pulse ; hoarseness, the voice becomes 
deeper, and finally quite deep ; the face is not bluish and 
bloated, but pale. 

Hartmann thinks that tracheal and bronchial croup is the 
proper sphere for Iodine, especially when there is a tendency 
to torpor, and he says that the Iodine-croup is always 
characterized by pain in the chest and larynx. I remember 
hearing Dr. Constantine Hering make the curious remark, 
that, while Bromine suited blue-eyed children, Iodine is 
adapted to black-eyed ones, and other observers have 
confirmed this. Hempel and Hartmann are at variance as 
to the precise pathological state, for Hempel says that it is. 



224 PSEUDO-MEMBRANOUS CROUP. 

the remedy, " especially in that stage of croup where the 
exuded lymph begins to become consolidated as an organized 
membrane, with suffocative wheezing and a fully developed 
croupy sound during the inspirations," while Hartmann 
affirms that " there are no symptoms pointing to a pseudo- 
membranous formation either in the larynx or the upper 
portion of the trachea." Here I consider that Hempel is 
undoubtedly correct, for in all my cases, in which Iodine 
proved curative, false membranes were present. Baehr gives 
a few needed words of warning not to be too ready to 
change the remedy. " In most cases Iodium will undoubtedly 
have a favorable effect. Only we must not indulge in the 
expectation of cutting the disease short. A result of this 
kind only occurs in a very small number of cases. Most 
commonly the pathological process continues to go on under 
the action of Iodine, after which it retrogrades, as is the case 
in every other inflammation. What is essential is that it 
should be kept confined within proper boundaries. Even if 
the dyspncea increases at first, this is no reason why the use 
of Iodine should be discontinued." 

As to the dose, Hempel recommends the mother-tincture ; 
Baehr the 2nd decimal dilution ; Elb the 2nd to the 6th 
dilutions (centesimal, I presume) and Hartman the 3rd or 
4th, going up to the 12th ; I have always used the 2nd or 
3rd decimal. Whatever preparation is used care must be 
taken to have it freshly prepared, as a dilution even a few 
weeks old is not to be depended on. Elb's hint must be 
kept in mind ; by attending to it I have succeeded where 
success seemed beyond my reach. In all forms of croup it 
is of importance not to intermit the medicines during sleep, 
for only by their constant employment is it possible, 
especially in the bad cases, to stop the progress of the 
disease." In the year 1858 Dr. William Arnold of Heidelberg 
introduced the use of Iodine inhalations in cases in which 
that remedy was indicated, but failed to cure when given in 
the usual manner. " The evident and visible effect of the 
Iodine-vapors was looseness of the cough, separation of the 



PSEUDO-MEMBRANOUS CROUP. 225 

membrane, and consequent greater facility of respiration. 
The mode of preparation was simply to pour a few drops of, 
from the strong tincture to the second dilution of Iodine 
into a shallow vessel filled with boiling water. The child 
was made to inhale the vapor by holding its head over the 
vessel, or in its immediate neighborhood. The preparation 
of the vapor was renewed more or less often, as it was 
needed, from every two to every six hours. At first the 
vapor appeared to be agreeable to the children, since they 
endeavored to approach the steaming vessel. Subsequently 
the effect seemed to be unpleasant, for two of the children 
resisted the application after the more violent attacks had 
been relieved." Drs. Hempel, Drake and Schlosser report 
remarkable success from this simple measure. 

To Dr. Allomge belongs the credit of introducing Bromine 
as a remedy for pseudo-membranous croup, and he asserts 
that it is the only remedy that can produce the false 
membrane in the larynx and trachea of the healthy. On 
the other hand, Dr. MeyhofTer, of Nice, thinks that Bromine 
is only of use in diphtheritic croup — when diphtheria extends 
to the air passages ; but it has unquestionably proved 
curative in severe cases of pseudo-membranous croup, as 
numerous reported cases testify, though Hempel says that 
it has been used with " variable and rather doubtful success." 
Hughes says that the specific action of Bromine on croup is 
unquestionable, and a writer in the British Journal of 
Homoeopathy i vol. V, thinks that "we must assign to Bromine 
the first place among the croup remedies we as yet know." 
Baehr is in doubt as to the place and power of this remedy 
in croup ; " instead of Iodine, many physicians recommend 
Bromine; some successful-cures with Bromine are reported, 
whereas others deny it all power over croup. We are not 
yet able to express a decided opinion on this subject," and 
again, " we do not mean to reject Bromine, but it is only in 
mild cases that we would substitute its use for that of 
Iodine." 

There is spasm of the larynx occasioning suffocation ; cough 



226 PSEUDO-MEMBRANOUS CROUP. 

with croup sound, hoarse, wheezing, fatiguing, not permitting 
one to utter a word". This cough is generally without 
expectoration, while with Iodine the cough is generally with 
expectoration ; the respiration is wheezing, alternately slow 
and suffocative, and hurried and artificial. In this remedy 
the respiration is with dry sound, while with Iodine the 
respiration is predominantly with moist sound ; the respira- 
tion is labored, painful and oppressed, with gasping for 
air; heat in the face; pulse rather hard, slow at first, and 
afterwards accelerated. Ruddock advises Bromine " in 
asthenic croup with extreme congestion and swelling of the 
air passages, so that the child breathes with great difficulty, 
throws his head back, grasps at the throat, and evinces 
anxiety. Affection of the upper part of the air tubes; dry, 
croupy cough, like that of a sheep, grating and tickling," and 
Dr. Guernsey's indications for Bromine in croup and laryn- 
geal diphtheria is " rattling of mucus in the windpipe when 
coughing," which is not very much of a "keynote," after all. 

The following appearances are found in the bodies of 
animals poisoned with Bromine : " Inflammation of the 
organs of respiration. A quantity of bloody foam in the 
larynx and trachea. Inflammation in the larynx, trachea 
and bronchi ; sometimes consisting of slight reddish stripes, 
sometimes of dark redness, sometimes of reddish coloring. 
Great inflammation of the larynx and trachea, with exuda- 
tion of plastic lymph, almost completely stopping up the air 
passages" {British Journal of Homceopatliy, vol. V). 

This remedy has usually been given in the form of dilutions 
prepared with distilled water — the 1st to the 3d being most 
highly recommended. The late Dr. E. H. Drake, of Detroit, 
has used inhalations of Bromine in this disease with eminent 
success. " My manner of using it is to take a drachm vial 
about half full of pure water, put in about four or five drops 
of Bromine — a part only of which will be dissolved, while 
the residue will fall to the bottom, and be taken up as fast 
as that already held in solution passes off by its exceeding 
volatility. Thus the solution may be kept of uniform 



PSEUDO-MEMBRANOUS CROUP. 227 

strength for twenty-four or thirty-six hours. The vial is 
then held to the mouth of the patient, so that the medicine 
will be inhaled through the mouth, which has seemed to 
answer better than when inhaled through the nose. The 
first few inspirations will cause resistance on the part of 
small children, on account of the unpleasant sensation it 
produces in the throat ; but by letting them take two or 
three, and waiting a short time, a minute or so, before 
renewing it, this is easily overcome. Most patients will take 
it while sleeping. Care should be taken to keep the mouth 
of the vial well closed with the finger or cork when the 
patient is not inhaling." Hughes mentions that Dr. Kafka 
has contributed to the Allgetneine Homoopathische Zeitung iox 
1875, a severe case of membranous croup in which inhala- 
tions of Bromine (1st and 2d decimal on cotton wool) had a 
most beneficial effect. 

Kali bichromicum is another remedy which has been used 
with success, and Dr. Hughes remarks that " there is a large 
accumulation of evidence tending to show that it is a potent 
remedy for true membranous croup," and in a later edition 
he says that it is " of all medicines, most homoeopathic to 
membranous croup— has frequently cured it." Dr. Hempel 
thinks that it may be used in the last stage when the 
membrane is formed, and I have seen some remarkable cures 
with this remedy, especially when the disease extended to 
the bronchial tubes. Dr. A. E. Small, of Chicago, writes : 
" I have found this remedy of the greatest use in arresting 
the progress of membranous croup when the attack comes 
on in the morning with hoarseness and accumulation of 
mucus in the larynx, tending to pseudo-membranous forma- 
tion. After a few doses of Aconite, the 3d decimal, to allay 
the arterial excitement, Kali bichromicum, the 3d decimal, 
in water, administered at short intervals, has produced a 
speedy cure." 

The following are the indications for this remedy as given 
many years ago by the British and Austrian practitioners. 
The symptoms approach gradually and insidiously ; at first, 



228 PSEUDOMEMBRANOUS CROUP. 

slight difficulty in breathing when the mouth is closed ; slight 
elevation of temperature ; pulse irregular and intermittent, 
or frequent and small; as the disease progresses, the difficulty 
of breathing increases; the sound of the air as it passes 
through the trachea is shrill, whistling, as if it passed through 
a metallic tube ; voice hoarse ; cough not frequent, but 
hoarse, dry, barking and metallic ; deglutition painful; tonsils 
and pharynx red, swollen and covered with an appearance of 
false membrane ; after a time, breathing affected in part by 
the action of the abdominal muscles, and those of the neck 
and shoulder-blades ; head inclined backwards ; breath 
offensive; finally, diminished temperature of the skin ; pros- 
tration ; stupor. Hughes says that the thickness and tenacity 
of the false membrane will always be an indication for this 
remedy. 

The English provers found the following morbid appear- 
ances on the bodies of dogs poisoned with this drug : 
" Epiglottis and rima glottidis congested and covered with 
thick, ropy mucus ; larynx and bronchi filled with muco- 
purulent matter. Mucous membrane of larynx, trachea and 
bronchi deeply injected. Larynx, trachea and bronchi lined 
with a false membrane, easily detached. In the bronchi 
polypus-looking masses which could be traced like cords 
through all the branches of the air tubes." {British [oiimal 
of Homoeopathy, Vol. V.) 

As to the dose, Hempel .recommends a powder of the 3d 
trituration dry on the tongue every two or three hours. I 
have, however, had the best results from a yellow-colored 
solution of the 2d decimal trituration, giving a teaspoonful 
every hour or half-hour, and in urgent cases I do not 
hesitate to give the 1st decimal trituration, similarly 
prepared. 

Many years ago I encountered a very fatal epidemic of 
pseudo-membranous croup, against which our usual remedies 
were not as successful as one could wish, while I noticed 
that allopathic treatment was worse than useless. In my 
extremity I applied myself to the study of the homoeopathic 



PSEUDO-MEMBRANOUS CROUP. 22o, 

Materia Medica — that monument of unwearied industry — 
and decided that Sanguinaria Canadensis was an appropriate 
remedy, as it presented the following symptdms : " ^Chronic 
dryness in the throat and sensation of swelling in the larynx, 
and expectoration of thick mucus. Aphonia, with swelling 
in the throat. ^Continual severe cough, without expectora- 
tion, with pain in the head and circumscribed redness of the 
cheeks. Tormenting cough with exhaustion and circum- 
scribed redness of the cheeks. *Croup." In the first 
volume of the Transactions of the American Institute 
of Homoeopathy I found that Dr. Bute, the original 
prover, considered it to be " very effective in croup." 
Soon after, I was called to an undoubted case of 
pseudo-membranous croup, and as I had no tincture of 
Sanguinaria in my office I gave minute doses of Sanguinarin 
in water, and the result was a rapid cure. In the course of 
my studies I read Professor Paine's Epitome of Eclectic 
Practice, in which he gives the following testimony as to the 
efficacy of Sanguinaria in this disease : " The Sanguinaria is 
one of the most valuable remedies known in the treatment 
of pseudo-membranous croup. It has proved as much of a 
specific for that disease as Quinine has for ague. I have 
seen it used in a great number of cases, and have never 
known a single failure, It should be made into an acetic 
syrup, by adding twenty grains of Sanguinarin to four 
ounces of vinegar ; steep and add one ounce of sugar to 
form a syrup. Dose, one teaspoonful as often as indicated." 
I frequently gave the remedy as Professor Paine directs, but 
finding that the large dose caused an unnecessary aggrava- 
tion, I reduced the quantity, and for a number of years I 
have used the following formula : dissolve two grains of the 
1st decimal trituration of Sanguinarin in three teaspoonfuls 
of good vinegar, adding six teaspoonfuls of brown sugar and 
twelve of water, and of this acetous syrup I give a teaspoon- 
ful every hour or every half hour. I have given the 
Sanguinarin in the 2d decimal trituration, dry on the 
tongue, but obtained better results from the acetous 



230 PSEUDO-MEMBRANOUS CROUP. 

preparation. Of late years I have used the tincture a good 
deal, especially since reading the following case, reported 
by Professor Helmuth, of St. Louis, now of New York, 
in the fourth volume of the American Observer : 

" We were called to see a child of some, ten years of age, 
who had been suffering from an attack of whooping cough, 
and who was taken with severe croup. The patient lived 
about seven miles in the country, and was in a most pitiable 
condition when we arrived. The previously-existing 
pertussis had much enfeebled him, and the croupy parox- 
ysms were decidedly the worst which, in fifteen years, we 
had seen. The suffocative fits were of the most distressing 
character, and the cough so severe that, as we passed to the 
house, the noise so resembled the barking of a dog tha,t we 
were certain that it belonged to the canine rather than to 
the human species. There were no other symptoms but 
these : constant croupy cough, excessive suffocation, 
hoarseness, with tossing about the bed to endeavor to gain 
air. He had taken for some time Aconite and Spongia, 
which had been administered by his parents, without any 
benefit ; also Hepar sulphur, with no good result. Having 
treated him before for severe attacks of this kind, we 
prescribed Ipecac and Kali bichrom., to *be taken every 
fifteen minutes in alternation, and being obliged to return to 
the city left Iodine and Tartar emetic to be taken if no relief 
was experienced after three hours' trial with the previous 
medicines. This was about twelve o'clock at noon. At 
midnight we were called again, and after an hour's ride found 
the little patient in what we then thought a dying condition. 
The pulse was almost gone, the face livid, the breathing 
rattling and stertorous, and every symptom indicating a 
most alarming state of suffocation. The medicines had been 
faithfully tried, but without result. While the vehicle was 
being prepared for the ride, we consulted Dr. Hale's New 
Remedies, and reading therein the remarks of Dr. Thomas 
Nichol, and being really at a loss what to prescribe, we took 
with us the tincture of Sanguinaria Canadensis. Of this were 



PSEUDO-MEMBRANOUS CROUP. 23 1 

mixed about twenty-five drops in half a glassful of water, and 
a dessert spoonful administered every ten minutes for half 
an hour. The symptoms began very gradually to abate, 
the breathing to become less labored, and the pulse conse- 
quently to become fuller. The medicine was continued, at 
longer intervals, with constant amelioration of the symptoms, 
and recovery resulted. We are of opinion that had it not 
been for the work of Dr. Hale this child would have died \ 
and en passant, would advise our friends to experiment with 
this valuable remedial agent in similar cases. We are aware 
many will say, " Where are the symptoms that called for it ? 
What was the ' key-note ' that demanded Sanguinaria ? '' 
There was no key-note but the rattle of death. There were 
no symptoms but croup in its last stages— suffocative 
breathing and asphyxia. 

Tartar emetic is the remedy most generally indicated 
when paralysis of the pneumo-gastric nerve threatens, though 
Baehr thinks it " is indicated if the dyspnoea and danger of 
suffocation are occasioned by movable patches of membrane. 
The cough is indeed feeble and without resonance, but a 
mucous rale is still distinctly heard in the trachea." The 
respiration is very short, the dyspnoea almost amounts to 
suffocation, the cough is loose and rattling, a shrill, whistling 
noise accompanies both expiration and inspiration, the child 
lacks the strength necessary to expectorate, the chest 
expands only on the most desperate efforts, and the anxiety 
and prostration are very marked indeed. The face soon 
becomes cold and bluish, the forehead is covered with a 
profuse cold perspiration, and the patient is almost in 
extremis. "Whilst Jahr considers it to be indicated when, 
after the removal of the dangerous symptoms, much mucous 
secretion remains, and in the opposite circumstances of a 
paralyzed state of the lungs. Bosch has recourse to it when 
the violence of the attack is apparently broken up (transition 
to the torpid croup ?) and others give it only when Hepar 
and Spongia have been ineffectually employed, without 
being able to assign a distinct ground for its selection." (Elb.) 



232 PSEUDO-MEMBRANOUS CROUP. 

My own opinion is that Tartar emetic is a remedy for severe 
catarrhal croup, but not for the more dangerous pseudo- 
membranous form. Elb recommends it in the 2d or 3rd 
dilution, while Baehr gives grain doses of the 2d trituration 
and cautions us " not to prescribe this remedy in large doses, 
for the favorable effect of the act of vomiting is very 
problematical, whereas the great depression caused by the 
vomiting is sure to follow." 

Phosphorus is recommended by Baehr if the cough has 
lost all resonance and force, and the mucous rale has ceased ; 
or more especially if the croupous process has invaded the 
bronchia, and the lungs have evidently become hyperaemic, 
and Elb says that it is most likely to do good when conges- 
tion of the lungs and heart with blood is to be regarded as 
the cause of the pulmonary paralysis. Elb recommends the 
2d or 3d dilution ; Baehr would not dare give it below the 
third attenuation. 

We owe the following indications for Bryonia to Elb, 
whose classical essay on croup should be in all hands. " The 
indications for this medicine are completely identical with 
those of Phosphorus for the remaining cough, only it is to 
be preferred in those cases where the cough is less deeply 
seated in the trachea or fever is still present." Dr. Alphonse 
Teste, many years ago, introduced Bryonia in alternation 
with Ipecac as remedies for croup. " Ipecac and Bryonia 
(but given concurrently, for both would be inert alone) are 
in all cases, whatever be the form of the attack or intensity 
of the disease, the great modifiers of croupal angina. These 
medicines need not be prescribed at very low dilutions — from 
six to twelve will suffice. The two solutions prepared, they 
should be administered alternately, a teaspoonful every two 
hours during the period of invasion ; every ten minutes during 
the exacerbations, and at intervals gradually increased, when 
these are passed." Jahr says that this was done " by the 
advice of a clairvoyant," and the late Professor Williamson, 
of Philadelphia, once told me that it was a communication 
from the spirit world. Here the Ipecac is prescribed against 



PSEUDO-MEMBRANOUS CROUP. 233 

the spasmodic element of the disease, and the Bryonia 
against the exudative inflammation, so that, this may be 
looked upon as a model of alternationist reasoning and 
practice. I used this prescription in former years, and found 
it effective against spasmodic croup, but utterly useless 
against pseudo-membranous croup. 

Aphorisms. 

1. Many of the epidemics of croup during the eighteenth 
century, would now be styled laryngeal diphtheria. 

2. Home and Cheyne remark that the younger children 
are when weaned, the more liable are they to pseudo-mem- 
branous croup. 

3. Pseudo-membranous croup is more prevalent among 
boys than girls, and robust, ruddy, healthful children are 
most likely to be attacked. 

4. Season and temperature exercise a much more powerful 
influence than constitution and temperament in the causa- 
tion of this disease. 

5. Croup is four times as frequent in the Winter quarter 
as in the Summer one, and the mean monthly temperature 
and the mean monthly mortality from croup rise and fall 
together throughout the entire year. 

6. While exposure to cold is the leading exciting cause of 
pseudo-membranous croup, it must be admitted t-hat in very 
many cases the exciting cause is absolutely inscrutable. 

7. Second attacks of pseudo-membranous croup are very 
rare. 

8. A family predisposition to this disease unquestionably 
exits, but so far it has not been proved to be hereditary. 

9. An obscure epidemic influence is sometimes associated 
with pseudo-membranous croup, and it is sometimes, but 
rarely, distinctly endemic, but it is never contagious, though 
diphtheritic croup is. 

10. Croup holds a place intermediate between the zymotic 
class of diseases and those of the respiratory organs. 



234 PSEUDO-MEMBRANOUS CROUP. 

11. Pseudo-membranous croup complicates measles, small- 
pox, scarlatina, whooping cough and typhoid fever, and the 
larynx is more or less implicated in the majority of cases of 
acute infectious disease. 

12. Croup is probably more influenced by peculiarities of 
country and climate than any other disease of the respiratory 
organs. 

13. A cold and moist atmosphere, with rapid alterations 
of temperature, together with the vicinity of the sea, make 
up the climate in which croup is almost endemic. 

14. Hoarseness in a child is of more moment than hoarse- 
ness in an adult, and roughness of the voice with hoarse 
cough should always suggest croup to the mother. 

15. In croup, the frequent cough is a better omen than 
the rare cough, and complete suppression of the cough is one 
of the worst signs. 

16. As a rule, pseudo-membranous croup is marked by 
remissions, which become shorter as the disease advances, 
but sometimes it marches directly onward to suffocation. 

17. The time for successful treatment is during these 
remissions. 

18. A sudden amendment is more likely to be followed by 
a relapse than a gradual one. 

19. The leading homoeopathic remedies are Aconite, 
Iodine, Bromine, Kali bichromicum and Sanguinaria ; minor, 
but still important ones, are Tartar emetic, Phosphorus and 
Bryonia. 



CHAPTER XI. 



Diphtheritic Croup. 



Diphtheritic croup is that most serious variety of croup 
which results from the development of the characteristic 
membrane of diphtheria upon the larynx and trachea, 
accompanied by the blood-poisoning which is part and 
parcel of the general disease. It calls for a separate essay 
on account of its very serious nature, and also because' many 
eminent writers and practitioners confidently assert that 
diphtheritic croup and pseudo-membranous are one and 
the same disease — that, in fact, pseudo-membranous croup 
is merely a sporadic laryngeal diphtheria. 

In all forms of diphtheria, and, indeed, in every case of 
the disease, its appearance in the larynx is to be dreaded 
beyond any other complication. The general opinion is that 
the diphtheritic membrane reaches the larynx by direct 
extension from the fauces, but Dr. Wade of Birmingham, 
England, asserts that he has never found the laryngeal 
exudation continuous with the pharyngeal. Dr. Ludlum of 
Chicago holds the opposite view : " The exudation may 
commence in the larynx or trachea, but is more prone to 
follow upon that which takes place in the fauces. Sometimes 
the curtain which envelopes the latter extends through the 
glottis into the vocal organ, and encroaches upon the trachea, 
even down to its bifurcation. Such a case would be 
accompanied by extreme dyspnoea." Oertel of Munich 
points out that " there are cases on record in which diphtheria 
localized itself first in the mouth, on the lips, and from 
these points, skipping the fauces entirely, at once attacked 
the larynx. Finally, there are rarer ones, in which the 



236 DIPHTHERITIC CROUP. 

diphthera involved the larynx first, and the mucous 
membrane of the fauces secondarily, while it also extended 
downwards into the trachea or bronchi." My own personal 
experience is, that as a very general rule, the disease 
originates by extension from the fauces, and that it is a very 
rare thing to find it originate in the larynx. I remember 
one notable case in which, when I first saw the patient, the 
only diphtheritic membrane to be found covered both eyes 
like two patches of very thick cream ; no membrane in the 
fauces and no laryngeal symptoms whatever. In twenty- 
four hours the larynx became inflamed, abundant diphtheritic 
membranes were thrown out, and the patient died forty- 
eight hours after the first appearance of the laryngeal 
symptoms. At death, no diphtheritic membrane was to be 
found in the fauces. 

The larynx is likely to be affected when the diphtheritic 
membrane covers the fauces very completely, extending very 
far down into the pharynx, though I have seen a number of 
cases in which large patches of diphtheritic membrane 
covered both tonsils, the mucous membrane of the pharynx 
being almost normal, when suddenly the dreaded laryngeal 
symptoms appeared, and that, too, at a very early period of 
the disease. This was possibly caused by multiple infection, 
but more likely by breathing the poison contained in the 
mouth and fauces — a true secondary infection. 

Physicians well read in historical medicine know that 
diphtheria is not, by any means, a new disease, but an old 
disease which manifests itself only at somewhat long 
intervals, and also that all writers on diphtheria make 
mention of diphtheritic croup. Areta^us, the Cappadocian, 
styled by Squire "the founder both of our knowledge and 
treatment of diphtheria," mentions that the disease, styled 
by him Egyptian and Syrian Ulcer, sometimes extended 
from the fauces to the windpipe, where it' proved rapidly 
fatal by suffocation, and he adds that children under puberty 
are especially subject to the laryngeal complication. The 
Spanish physicians Herrera, Villa Real and Fontecha, who 



DIPHTHERITIC CROUP. 237 

wrote in the beginning of the seventeenth century, give in 
their works most excellent descriptions of the .disease which 
we call diphtheria, styled by them garrotilla or morbus 
sujfocans* on account of the laryngeal complication. Alay- 
mus, who describes the diphtheria epidemics of Sicily in the 
early part of the seventeenth century, speaks of the disease 
as extending to the - larynx, and also of its commencement 
there. In the year 1753, Dr. Cadwallader Golden, of New 
York, observed a disease which could only be diphtheria. 
" It is attended with a moist, putrid heat, the skin being 
seldom parched. The pulse is usually low, but frequent and 
irregular. The countenance dejected, with lowness of spirits ; 
no considerable thirst ;. the tongue much furred, and the 
furring sometimes extends over the tonsils as far as the eye 
can reach. At other times, in the mildest kind, the tonsils 
appear only swelled, with white specks of about a quarter 
of an inch or half an inch in diameter, which are thrown off 
from time to time in tough cream-colored sloughs. Some- 
times all the parts near the gullet or throat are much swelled, 
both inwardly and outwardly, so as to endanger suffocation, 
and frequently mortify; but most generally the swelling 
internally is not so much as to make swallowing difficult. 
Sometimes those swellings imposthumate. The last com- 
plaint is commonly of an oppression or strictness in the 
upper part of the chest, with difficulty of breathing, and a 
deep, hoarse, hollow cough, ending in a livid, strangled-like 
countenance, which was soon followed by death." From the 
last sentence we are led to conclude that croup, undoubtedly 
diphtheritic in its nature, was the usual termination of the 
disease, and the same peculiarity has been observed in other 
epidemics. ft 

In the year 1755, Dr. Richard Russell, of London, noted 
croup in connection with an epidemic of malignant angina, 
and there can be little doubt but that in our day that this 
malignant angina would be styled diphtheria, and that the 
accompanying croup was diphtheritic in its nature. Ten 
years later Francis Home wrote his classic work in which he 



238 DIPHTHERITIC C^OUP. 

describes what we now style pseudo-membranous croup, and 
he was very careful to draw the diagnostic lines between it 
and diphtheritic croup, which he had certainly seen. In 
1779, Dr. Johnstone, of Kidderminster, insisted on the essen- 
tial difference between the two diseases, but, in the words of 
Dr. Squire, " Unfortunately, though argued with learning 
and experience, these views did not prevail ; the name of 
croup was applied to the epidemic complication, and the 
treatment laid down by Home for the one disease was very 
energetically employed against the other." The epidemics 
of croup at Cremona and Liskeard, referred to in the chapter 
on pseudo-membranous croup, appear to have been closely 
akin to the disease described by Dr. Richard Russell, and 
the latter half of the eighteenth century and the first years 
of the nineteenth are notable for numerous outbreaks of 
malignant angina associated with laryngeal inflammation. 
The " Suffocative Angina," so well described by Dr. Samuel 
Bard, of New York, in 1771, appears to have been identical 
with diphtheria, and he remarks that he saw upon several 
children in the same family thick, coriaceous pellicles formed 
upon the tonsils, and propagated from the pharynx to the 
trachea. " Three post-mortem examinations exhibited to 
him, as a uniform result, white, thick, coriaceous, elastic 
layers of concrete matter, which lined the walls of the 
pharynx. A membraniform tube of the same nature 
advanced into the trachea and became progressively thinner 
in proportion as it descended into the bronchi. The tracheal 
mucous .membrane was slightly inflamed ; that of the 
pharynx, after the pellicles were removed, was found rather 
pale." Dr. Squire claims that the disease seen by Dr. Bard 
was diphtheria, and certainiythe description of the laryngeal 
complication exactly tallies with diphtheritic croup, while it 
is quite unlike the morbid state which we call pseudo-mem- 
branous croup. To quote Dr. Squire : " Epidemic croup is 
strictly diphtheria; when that disease prevailed epidemically 
in England at the end of the last century, any fresh outbreak 
was so spoken of; an outbreak at Chesham, in Buckingham- 



DIPHTHERITIC CROUP. 239 

shire, in 1793, carefully described by Mr. Rumsey, leaves no 
doubt upon this point ; sometimes on its appearance in a 
fresh locality it was simply called croup, and the word 
excited as much terror then as diphtheria has again given 
us reason to associate with the disease it now designates." 

Many of the essays presented to the great Parisian 
concours on croup (1807) really describe diphtheritic croup, 
and confusion reigned till in 181 8 the illustrious Bretonneau 
investigated the epidemic of diphtheria at Tours. The 
conclusions at which he arrived have influenced the views of 
French physicians down to the present day, and, as is well 
known, the vast majority of them agree in considering that 
diphtheria and true croup are one disease, the latter being a 
mere local manifestation of the former. A goodly number of 
practitioners, among them Bricheteau, Emangard and Des- 
ruelles, opposed these views, and the original work of Dr. 
Bland, of Beaucaire, entitled Nouvelles Reclierclies sur la 
Laryngo-Tracheite is even to-day one of our best authorities 
on the subject. In 1820, Dr. Mackenzie, of Glasgow, 
described a disease strikingly similar to that seen by Breton- 
neau, and from that date the two diseases were described 
separately. In 1826, Dr. Abercrombie described a fatal 
throat affection extending to the windpipe, which was very 
fatal among the children in Edinburgh, and he adds that "it 
is evidently quite distinct from the idiopathic inflammation 
of the mucous membrane of the larynx to which we com- 
monly apply the name of croup." During the succeeding 
decades, a malignant angina, unquestionably diphtheritic in 
in its nature, often accompanied by a laryngeal complication, 
raged at intervals in the three Kingdoms, and the laryngeal 
complication was always carefully distinguished from true 
croup. 

In 1858, the great epidemic of diphtheria invaded England, 
and though diphtheritic croup was at first considered to be a 
distinct affection from pseudo-membranous croup, Dr. Prosser 
James, in the first edition of work, Sore Throat, its Nature, 
Varieties and Treatment, contended that " both are alike the 



240 DIPHTHERITIC CROUP. 

manifestation of an inflammatory condition tending to 
exudation " — exudation being, in fact, regarded as the grand 
characteristic of the disease. Dr. R. H. Semple, who had 
probably been inoculated with the French views while trans- 
lating Bretonneau's Memoirs for the New Sydenham Society, 
had long held that the two diseases are really one, and 
towards the close of the epidemic (1868) Dr. Thomas Hillier, 
a distinguished writer on the diseases of children, declared 
that he could detect no difference between membranous 
croup and laryngeal diphtheria. A few years later Dr. 
George Johnston and Dr. Morell Mackenzie, the greatest 
authority on throat diseases in Great* Britain, gave in their 
adhesion to the new doctrine, and in 1870, Sir William 
Jenner, who had long held that the two diseases were 
distinct entities, finally pronounced himself " inclined to 
think that the two diseases are really identical." Sir William 
enunciated his new views with great force and eloquence at 
a debate on the subject at a meeting of the Royal Medico- 
Chirurgical Society. The discussion originated in the report 
of a committee recommending that the word " croup be 
henceforth used wholly as a clinical definition, implying 
laryngeal obstruction, occurring with febrile symptoms in 
children " — a doctrine which, if acted upon, would turn the 
pathology of the subject backward two centuries. 

In the United States the greatest names in pathology — 
George B. Wood, Austin Flint, J. Lewis Smith, Fordyce 
Barker,Henry Hartshorne and others — hold that true croup — 
pseudo-membranous croup — is a wholly distinct disease from 
laryngeal diphtheria, and I can only recall two names of 
note, J. F. Meigs and A. Jacobi, who hold the contrary view. 
Dr. Jacobi attributes this result to the influence of the 
writings of Vogel and von Niemeyer upon the American 
medical mind, and certain it is that the views of Meigs and 
Jacobi are held by but a small majority of the medical men 
of this continent. 

In Germany, many eminent pathologists, among them 
von Niemeyer, Oppolzer, Letzerich, Vogel, with Rudolph 



DIPHTHERITIC CROUP. 24 1 

Virchow, the most eminent of them all, deny the unity of 
diphtheria and pseudo-membranous croup. Steiner talks on 
both sides of the question, stating that '* the attempt to 
distinguish croup and diphtheria as' two entirely distinct 
diseases has been unsuccessful, both from an anatomical and 
from a clinical standpoint." Yet. he concedes that " in 
diphtheria the lesion is similar to that of croup, only with 
this difference, that in croup the exudation takes place upon 
the free surface of the mucous membrane, while in diphtheria 
it occurs at the within the tissue, and thus produces necrosis 
and loss of substance of the mucous membrane." This is 
an important distinction from the anatomical standpoint, 
and he finally admits that while " true croup is not a conta- 
gious disease," " diphtheritic croup possesses this quality in 
a marked degree," which is certainly of great moment from 
a clinical standpoint. 

In some epidemics the appearance of the diphtheritic 
membrane on the larynx and trachea is of common occur- 
rence, while in other epidemics it is very rare. Why it is so 
we cannot tell, but though unexplained, still the fact remains 
a fact. In low, swampy land, and on the banks of lakes and 
ponds, laryngeal diphtheria is far more common than on 
high, rolling land. While practicing in Simcoe, Province of 
Ontario, I found that diphtheritic croup was more apt to 
appear near Lake Erie than at a distance from it, and that 
a river or creek had not the same deleterious effect as bodies 
of standing w r ater. So common was laryngeal diphtheria in 
some of the Spanish epidemics of the seventeenth century, 
that the entire morbid state was styled morbus strangulato- 
rius or garrotilla. It was very common in the famous 
epidemic of Tours, so well described by Bretonneau. " In 
comparing together the morbid lesions observed in fifty-five 
subjects of all ages, who, in the course of two years had 
fallen victims to epidemic angina, I find that it once 
happened that the false membrane existed in the trachea 
without any exudations being found either upon the tonsils 
or upon any other part of the pharynx. Six or seven times, 



242 DIPHTHERITIC CROUT. 

that is to say, in the proportion of one to nine, the membran- 
iform exudation reached to the extreme ramifications of the 
bronchi. In a third of the whole number it passed beyond 
the great division ; in all the rest it terminated at different 
distances from the trachea, so that the mechanical obstacle 
offered to respiration by the development of the false 
membrane always appeared to be the immediate cause of 
death. A single- exception was observed. A child who 
appeared to die of exhaustion, on the fifteenth day, from 
malignant angina, without any other symptoms than a 
continuous vomiting, had the pharynx lined with thick 
pellicle, which did not pass beyond either the commence- 
ment of the oesophagus or the entrance of the glottis" 
{Bretomieaii s First Memoirs, 1821). Mr. Thompson, of 
Launceston, England, says that of 485 cases which came 
under his observation, the air passages were involved in only 
fifteen, eleven of them dying within a few hours of the 
commencement of the croupous breathing. Mr. Schofield, 
of Highgate, near Birmingham, had thirteen fatal cases of 
diphtheria in his practice, in three of which it assumed the 
form of croup. Dr. J. F. Meigs, of Philadelphia, lost six 
patients with diphtheria, and " in all but one the fatal 
termination was caused by the extension of the exudation 
to the larynx." Dr. Capron, of Guilford, England, had nine 
fatal cases of diphtheria, three of them dying croupous. Dr. 
Heslop, of Birmingham, England, thinks that the disease 
attacked the larynx in about five per cent, of the cases he 
had seen in that city. Of 26 fatal cases of diphtheria 
reported by correspondents of the British Medical Journal 
(1859) nme > including one from bronchitis, died from the 
laryngeal complication. Dr. Squire remarks that two-thirds 
of his cases of diphtheria suffered from laryngeal complica- 
tions, and that the mortality was very high, about 80 per 
cent, of the croupous cases. This closely corresponds with 
the statistics of M. Roger, for the Children's Hospital in 
Paris, in 1859 ar) d i860, which show a mortality of about yj 
per cent, in laryngeal diphtheria. Dr. Crichton, of Edin- 



DIPHTHERITIC CROUP. 243 

burgh, gives the results of 45 cases of diphtheria observed 
in his practice. Of these, 25 were males- and 20 females; 
nine proved fatal, or 20 per cent. Six of the deaths were 
from extension of the diphtheria to the larynx, and the 
remaining three died of asthenia. The average age of the 
fatal cases was seven years. Dr. Hillier says that " of the 
cases of diphtheria that have occurred in the Children's 
Hospital (London) two-thirds of the cases have suffered 
from laryngeal complications." Meigs and Pepper remark 
that "the frequency of its occurrence varies much in different 
epidemics, the proportion varying from one or two per cent, 
to as high as fifty per cent, of all the cases." Oertel thinks 
that " the younger the patient the greater is the danger that 
even the lighter forms of the disease may involve the larynx, 
while the more extensive inflammations take this dangerous 
course almost invariably." Jacobi, whose immense experi- 
ence entitles him to the most respectful consideration, says, 
" I do not know that sex exerts any predisposing influence 
over diphtheria, yet of the 600 cases or thereabouts of 
laryngeal diphtheria in which I either personally performed 
tracheotomy, or observed the progress of the disease in the 
practice of others, I found the majority in males, and the 
recoveries in inverse proportion to the number thereof; the 
mortality being greater among boys." The writer has seen 
over eighteen (18) hundred cases of true diphtheria, besides 
many hundreds of cases of pseudo-diphtheria — a form of 
morbid action which may be said to bear the same relation 
to true diphtheria' that cholera-morbus does to Asiatic 
cholera — and the result of his observation is, that laryngeal 
symptoms have appeared in eighteen per cent, of all the 
cases of true diphtheria seen from 1858 to 1870, and only 
three per cent, in all cases of true diphtheria seen from 1871 
to 1884. I have never observed laryngeal complications in 
all the cases of pseudo-diphtheria. Of those attacked with 
diphtheritic croup, a very large proportion died — not less 
than seventy per cent. — and the fatality was largely influ- 
enced by the locality. 



244 DIPHTHERITIC CROUP. 

Diphtheritic croup, then, appears in two forms, as an 
idiopathic affection and as an extension of the disease from 
the fauces; the first form is quite rare, the second is the 
most common phase of the malady. When it appears as an 
idiopathic disease the local symptoms are commonly preceded 
for some days by slight fever, which is, in the early stage, 
much less severe than in the case of pseudo-membranous 
croup ; and from the very faintest inception of the morbid 
process, an amount of depression is present which is out of 
all proportion to the local symptoms, for the very source of 
life is already being prostrated by what some English writers 
oddly term a " morbid poison." It must be noted that as 
soon as the exudative inflammation attacks the larynx, the 
fever rises at once, and, curiously enough, the feeling of 
prostration seems to pass away to a considerable extent. 
Jacobi accurately remarks that " fever and pain are not 
necessarily prominent symptoms," and in some of my worst 
cases the patients had hardly any fever and made no 
complaint of pain. Soon a slight cough, not at all hoarse, 
comes on, and this is preceded for as much as twenty-four 
hours by a slight trilling sound in the larynx, only to be 
detected by ausculation, which should constantly be used in 
all cases of diphtheria. But this slight and apparently 
trifling cough speedily assumes the loud, clangorous character 
of a true croupous cough, and, at the same time, the respira- 
tion becomes stridulous. The cough, which evidently causes 
great suffering to the child, has, in the graphic words of 
Oertel, "a peculiar, barking, flat sound without resonance," 
which an experienced ear can readily differentiate from the 
cough of pseudo-membranous croup. The roughness and 
hoarseness of the voice increases with alarming rapidity, and 
soon complete aphonia sets in, though the mere act of 
speaking seems to cause no pain. Inspiration is very slow, 
long-drawn and whistling, while expiration is short and 
superficial. Suddenly, a frightful paroxysm of dyspnoea sets 
in, apparently caused by spasm of the laryngeal muscles. 
Suffocation now appears to be imminent ; the child cannot 



DIPHTHERITIC CROUP. '245 

lie down ; the pale, bluish skin is covered with perspiration, 
and all the powers of life fail rapidly. I have known death 
occur during one of these paroxysms, and this is apt to be 
the ease when a feeble child has been thoroughly saturated 
with the diphtheritic poison. As a general thing, however, 
the paroxysm passes away and is replaced by an interval of 
comparative ease and restfulness, but soon another paroxysm 
comes on with still more alarming phenomena, leaving the 
child still more exhausted. The intervals between the 
paroxysms become more and more brief till the child 
becomes comatose and passes quietly away. 

Another group of cases presents very similar symptoms, 
but without the distressing paroxysms of suffocation. In 
these the pseudo-membrane forms and thickens, the cough 
becomes more frequent and more severe, and the disease is 
quite similar to true croup, but with less febrile 
reaction, and with the peculiar - cough already 
described. As the larynx becomes more and more 
blocked up with the diphtheritic membrane, the respiration 
is quickened and the dyspnoea finally becomes extreme ; the 
inspiration is whistling and very much protracted; the face 
is pale and anxious ; the sufferer vainly seeks for relief from 
change of posture, and finally death ensues, though, as Dr. 
Charles West accurately remarks, " without being ushered in 
by that urgent dyspnoea and those violent efforts to obtain 
air which attend most cases of cynanche trachealis." The 
cough is weaker and less frequent as death approaches. 

In the second class of cases the patients are attacked with 
diphtheritic croup in the course of the ordinary pharyngeal 
diphtheria. It may either come on suddenly, or the exten- 
sion may be marked by a little huskiness and weakness of 
the voice, while the breathing is irregular and imperfect. 
Soon the well-known cough comes on with extreme dyspnoea, 
sopor supervenes, and death closes the scene often within a 
few hours of the laryngeal attack. Dr. J. Lewis Smith says 
that " occasionally, by great effort on the part of the child 
or by fortunate treatment, a portion of the pseudo-membrane 



246 DIPHTHERITIC CROUP. 

is expectorated, and for some hours there is apparently great 
improvement, but it is only in exceptional cases that the 
plastic formation is not speedily and fully reproduced." 

In patients in whom the disease has extended from the 
fauces to the larynx, the glands of the neck and throat swell, 
the tongue gets very red, especially at the tip, and a thick, 
yellowish fur of foul smell covers the entire organ. The 
breath is extremely offensive, and a thin and fetid fluid runs 
from the nose and eyes, and, if the patient lives long enough, 
false membranes form on both nose and eyes. The urine is 
scanty and high-colored, and albuminuria appears about the 
fifth or sixth day. At times the urine is wholly suppressed, 
and I have never known these cases to recover. Oertel and 
Henoch think that diphtheria of the trachea rarely occurs 
without the co-existence of diphtheria in the fauces, but I 
have repeatedly remarked it, but not of late years. 

In patients in whom the disease is primarily developed in 
the larynx, precisely the same group of symptoms makes its 
appearance, but not so virulent, unless, indeed, the patient 
should live a week or longer after the appearance of the 
laryngeal diphtheria. 

When a favorable termination is about to take place, 
improvement may be looked for about the third or fourth 
day. One of the earliest of the favorable signs is the 
increased facility of swallowing, and this may take place 
even when the pharynx and its diphtheritic membrane is 
apparently unchanged. Next, membranous shreds are expec- 
torated, or still more frequently they are swallowed. Some- 
times such a mass of them passes into the intestinal canal 
that the patient is made quite sick, and this is one of the 
very few instances in which the homoeopathic physician is 
justified in administering a laxative. On examining the 
stools, large quantities of the characteristic membrane are 
found, and the patient soon brightens up on being relieved 
of the offending substance. Tolle cansam. The fever 
decreases, and is succeeded by long-continued sweats ; the 
alarming laryngeal symptoms decline, though hoarseness the 



• DIPHTHERITIC CROUP. 247 

result of a partial paralysis of the vocal cords together with 
weakness of the laryngeal muscles, lasts for quite a time 
after restoration to health ; nosebleed comes on without any 
assignable cause ; and the quantity of urine is greatly 
increased, while, at the same time, the albumen finally 
disappears. 

During the process of cure, important changes take place 
in the diphtheritic membrane itself. We see these changes 
in the pharynx, and we infer that similar changes take place 
in the laryngeal membrane. Dr. D. Francis Condie gives 
the following excellent account of these changes: "In 
favorable cases, as the membranous exudation becomes 
detached its place is quickly supplied by a new formation, 
and after each separation it becomes, in general, white, and 
much thinner. In other cases, the exudation, instead of 
being separated in fragments, becomes, in part, softened to 
a pulpy consistence, and is discharged from the mouth mixed 
with bloody mucus. This separation and renewal of the 
pseudo-membranous deposit continue, in most cases, for the 
space of eight or ten days. When, finally, it ceases to 
appear, it leaves, most generally, the mucous membrane to 
which it has been attached perfectly sound throughout its 
whole extent ; of a light-red, uniform color, and covered, 
usually, with a thick, yellow mucus, more or less resembling 
pus. At the same time the aspect of the child is greatly 
improved. The features brighten and lose the dull and 
haggard look which characterizes all serious diphtheria ; the 
tongue becomes moist and clean ; the skin warmer, moister 
and more natural, and slowly, very slowly, the patient 
regains his former health and strength." 

On the other hand, should the case be about to terminate 
unfavorably, the disease marches on with steady and rapid 
strides ; the respiration becomes more and more stertorous ; 
the cough becomes weaker, and finally is entirely suppressed; 
the face becomes livid and ghastly ; the skin cool and of a 
dull, dusky, purple hue ; the child sinks into a partially 
comatose state, and death often takes place, as Dr. Ludlam 
remarks, " without a sigh or a groan." 



248 



DIPHTHERITIC CROUP. 



Dr. Thomas Hillier remarks that " the laryngeal symptoms 
set in on the first, second or third 'day ; in a very large 
proportion of cases within the first week," and he adds that 
he has " seen them occur once on the twelfth and once on 
the nineteenth day of the disease." Dr. J. F. Meigs says : 
" If it extend into the air passages very soon after the 
invasion, it may cause death within a few days. In most of 
the cases, however, the larynx does not become implicated 
under five or six days. In one of my cases death occurred 
on the fourth day, in one on the fifth, in one on the sixth, 
in two on the seventh, and in one on the eighth." Dr. J. 
Lewis Smith gloomily and yet accurately remarks that "when 
the croupy cough, voice and respiration are observed, he will 
seldom err who predicts a fatal result within a week, and 
often death follows in two or three days." Oertel's experi- 
ence is " that diphtheria of the larynx and lower air passages 
in children usually runs its course in a few days ; in from 
two to eight days, or more rarely as late as the tenth or 
twelfth day, either a fatal termination or convalescence takes 
place." / 

Dr. Charles West gives the following interesting table of 
27 cases of diphtheria in which death took place chiefly from 
the affection of the larynx : 

The child died on the 2nd day in 1.. 



My own experience is very 



■cilia Kxay 1 
3rd " 


1 j .. 

4 


4th 


I. 


5 th 


4- 


6th 


3- 


7th 


1. 


8th 


1. 


9th 


1. 


10th 


1. 


nth 


1. 


12th 


1. 


13th 


3- 


14th 


1. 


15th 


2. 


2ISt " 


1. 


23rd 


1. 


j similar 


to 



that of the 



DIPHTHERITIC CROUP. 249 

distinguished authors just quoted. Much depends on the 
malignancy of the general disease, but when diphtheritic 
croup is really developed, death usually takes place within a 
week of the invasion of the laryngeal symptoms. Indeed, it 
may be said to be a general rule that when death takes place 
in diphtheria within a week, it is by extension of the disease 
to the larynx. Very few croupous cases live to see the 
commencement of the second week, for, when death takes 
place after the expiration of the first week, it is very 
frequently caused by exhaustion. It is true that I have seen 
the disease developed as late as Dr. Hillier has observed, 
but then it could always be traced to an accidental exposure 
to cold. 

In diphtheritic croup death may be the result of a severe 
and long-continued spasm of the glottis, which seems to be 
of the essence of the paroxysms already described, or it may 
arise from a purely mechanical blocking up of the larynx, 
trachea or bronchi by the diphtheritic membrane, or, lastly, 
death may, according to Oertel, result from insufficient 
decarbonization of the blood, due to its unequal distribution;" 
this inequality in the distribution of the blood is due to the 
fact that emphysema and anaemia have established them- 
selves in the parts open to the circulation of air, while in 
the collapsed parts, to which the air does not have access, 
there is hyperemia. Later in the course of the disease, 
pneumonia may set in, or pulmonary oedema, and if the 
patient should surmount these manifold dangers there 
remains the blood-poisoning of the primitive disease, which 
may prove fatal even months after all danger from the 
respiratory organs has passed away. As a general rule, it is 
rare to find one of these causes of death acting singly and 
alone, for the diphtheritic blood-poisoning is an almost 
invariable factor in the fatal result. 

If the throat is examined in the early stages, the fauces, 
soft palate and tonsils will either be found to be of an 
universal purplish red, or marked and blotched with the 
same hue. This redness is succeeded by a thick, albuminous 



250 DIPHTHERITIC CROUP. 

lymph, which is more abundant at the base of the arch of 
the palate than above it, looking as if it had extended from 
the larynx. The contrary is the case when the larynx is 
secondarily affected, for then the lymph is more copious at 
the summit of the arch of the palate. 

Dr. Paul Guttmann, of Berlin, observes that " Very young 
children, who are most frequently attacked by laryngeal 
diphtheritis, can very seldom be subjected to laryngoscopy 
examination ; the affection, however, can usually be diagnosed 
without it, as we know from experience that symptoms of 
stenosis of the glottis (crowing and prolonged inspiration), 
and hoarseness or aphonia, when they present themselves 
along with diphtheritis of the pharynx, are always due to an 
extension of the disease to the larynx. Even when the 
pharyngeal diphtheritis is wanting the above-mentioned 
indications, when observed in young children in districts in 
which diphtheritis is prevalent in an epidemic form, generally 
warrant one in assuming confidently the diphtheritic nature 
of the laryngeal affection." Oertel gives the following sketch 
of the results of the laryngoscopic examination made in 
children sick with laryngeal diphtheria : " All the parts of 
the larynx will be found intensely reddened and swollen, the 
epiglottis thickened to twice its natural size, and the yellow 
colour of the cartilage, which normally shows through its 
covering, no longer distinguishable ; the aryteno-epiglottidean 
folds, the false and true cords, are greatly swollen, and are 
covered, more or less, with a grayish-white exudation, or the 
interior of the larynx itself is lined with a white, leather-like 
covering, and the glottis is narrowed. Tenacious exudation 
and purulent mucus, which push up from the deeper parts 
of the air-passages, often adhere between the vocal cords, 
and are driven up. and down in the narrow cleft by the 
forced respiration." 

It is well to remember that, even when the lungs are not 
directly implicated, the respiratory murmur is so overwhelmed 
by the loud, laryngeal sounds that no vesicular murmur can 
be detected by auscultation. 



DIPHTHERITIC CROUP. 25 1 

The pseudo-membranes found in the larynx vary much in 
consistence, extent and appearance. Sometimes it is soft, 
gelatinous and almost liquid, lying loose in the throat, almost 
like a clot of cream, with its particles so soft and so little 
connected with each other that it almost seems a misnomer 
to apply the term i pseudo-membrane ' to it. At other 
times it resembles a fragment of moist kid glove leather — 
dense, elastic, coherent, and as thick as a silver half-dollar. 
I remember examining one pseudo-membrane, in i860, the 
upper part of which was a quarter of an inch in thickness, 
and of horny hardness. It was lying almost loose in the 
fauces, and on being removed, it was perfectly reproduced 
in twenty hours. Between these extremes one meets with 
membranes of great variety as regards thickness, cohesion 
and appearance. The more liquid membranes are whitish or 
yellowish-white in color, while the denser ones are grayish, 
or ash-coloured, and sometimes brown or blackish. 

On examining, after death, the bodies of those who have 
died of diphtheria of the air passages, the epiglottis is often 
found to be so enormously swollen as to close the entrance 
to the windpipe. It is also covered on both sides, or on one 
only, with the characteristic exudation, on removing which, 
small points of ulceration are found studding the surface. 
This exudation is not an effusion upon the free surface of 
the mucous membrane, but an exudation within the tissue 
as well, and it often destroys both mucous membrane and 
epithelium. The larynx is lined with a similar pseudo- 
membrane, generally whiter than the diphtheritic membrane 
found on the tonsils and pharynx, on removing which, an 
ulcerous surface, raw and sore, is seen, for diphtheria — at 
least in its local manifestations in the fauces and air passages 
— is simply a specific inflammation with partial necrosis and 
sloughing of the mucous membrane. The diphtheritic 
membrane is not so easily pulled off as the pseudo-membrane 
of true croup, for in the latter disease an effusion between 
the mucous membrane and the pseudo-membrane is an effort 
of nature to cure the disease. But in. diphtheritic croup 
the mucous membrane dies, if the case lasts any time. 



252 DIPHTHERITIC CROUP. 

Dr. Charles West remarks that he has " in no instance 
observed false membranes extending below the larynx," but, 
in common with many other physicians, I have seen complete 
casts of the trachea, bronchi and bronchial tubes, even to 
the third bifurcation. In the upper part of the trachea the 
pseudo-membrane is similar to that lining the larynx, but as 
it descends it becomes thinner and less consistent, till it 
tapers off to a very tKin and transparent pellicle. In some 
ten or twelve cases I have noticed blood that had been 
accidentally drawn, and it was always of a dark brownish 
hue and deficient in coagulability. 

Is psetido-membranous croup identical with diphtheritic 
croup ? Is each case of pseudo-membranous croup merely a 
sporadic case of laryngeal diphtheria ? This is one of the 
burning questions in pathology, and yet it has been strangely 
ignored by almost all the authors of our school who have 
written on diphtheria or on croup. The question at issue is 
thus temperately stated by Drs. Meigs and Pepper : " But 
further, our personal experience constrains us to state that 
the differences between the two forms of membranous-croup 
above enumerated have not seemed to us sufficiently marked 
and constant to positively establish their essential diversity ; 
and that it is our decided opinion that the vast majority of 
the cases usually termed pseudo-membranous laryngitis 
(pseudo-membranous croup) are, in reality, instances of 
primary laryngeal diphtheria (diphtheritic croup), in which 
the constitutional symptoms are not grave, and where the 
faucial deposit has been very slight and perhaps even over- 
looked." 

As already remarked, this view is held by the great mass 
of French pathologists, a large number of the Germans, and 
a small but respectable minority of the English, while on 
this continent the contrary view is very generally maintained. 
Another view is taken of this deeply interesting and 
important subject by a large body of medical men, who 
look upon diphtheria, in the words of Dr. Charles West, as 
being " a second form of disease, resembling croup in some 



DIPHTHERITIC CROUP. 253 

respects, though differing in others, alike but not the same." 
This is the view held by the present writer,- who considers 
that while the distinction between the two maladies is 
sufficiently marked in typical cases, that in a small number 
of instances there is a tendency in one disease to run into 
the other, precisely as every experienced practitioner has 
met with cases of disease which taxed his diagnostic skill to 
decide whether they were small-pox or chicken-pox. Further, 
it is freely conceded that diphtheria implicating the air- 
passages, must, in the very nature of things, produce 
symptoms strikingly similar to those of croup, but that by no 
means proves their identity, for a foreign body in the larynx 
simulates croup very closely. But, as a very general rule, 
the non-epidemic, non-contagious, sthenic, localized inflam- 
mation of true croup is readily distinguished from the 
epidemic, contagious, asthenic, general disease which we 
style diphtheritic croup, in which the local inflammation is 
merely one of the many incidents of a deeply-pervading 
constitutional affection. 

Dr. Jacobi of New York propounds the following queries : 
" Can pseudo-membranous croup be distinguished from 
laryngeal diphtheria ? Ought these terms to be preserved 
separately? Are they different processes ?. Let us suppose 
two cases of membranous impediment in the larynx, the one 
with, the other without membrane in the pharynx, the other 
symptoms being the same, is one " diphtheria of the larynx," 
and the other " croup " ? Suppose again, a membranous 
stenosis of the larynx, to which is only later added a 
membrane of the pharynx, was the case originally one of 
" croup " which became a " diphtheria " later on? Thirdly, 
take two cases of laryngeal stenosis, one with symptoms of 
suffocation only, the other having these symptoms together 
with adynamia; is the latter " diphtheria" alone, the former 
only " croup " ? In my opinion, it is just as little possible to 
differentiate these diseases according to the seat of the 
morbid product, as it is justifiable to deny the title 
diphtheria to membranous pharyngitis when few general 



254 DIPHTHERITIC CROUP. 

symptoms, such as fever, debility and collapse, happen to be 
present." To these queries Rokitansky's definitions are a 
sufficient reply : " Croup is a fibrinous exudation effused 
in a liquid form, and coagulating on the surface of the 
mucous membrane, this being unaltered or nearly so," and, 
u Diphtheria is a necrotic process, consisting in infiltration 
of the mucous membrane, accompanied by exudation and 
followed by sloughing," and the chief point of resemblance 
is that both are manifestations of an inflammatory condition 
tending to exudation. As Herschel clearly points out, 
croup is a plastic disease, while diphtheria is a gangrenous 
one, and this dicttim holds good, even though the diagnosis 
of some few cases baffles the most experienced. 

Hirschel points out that while in diphtheria the sub-mucous 
tissue is affected, besides the mucous membrane, in croup 
only the mucous membrane is the seat of the disease, while 
L. Fleischmann considers that the membrane of croup is a 
true pseudo-membrane lying on the surface of the mucous- 
membrane, from which it can be removed, while the 
membrane of diphtheria is never a true croup-membrane, 
but deposits consisting of degenerated and exfoliated 
epithelium, fungi and detritus. Dr. T. H. Green observes, 
" It is difficult in many cases to draw any line of demarcation 
between*the histological changes occurring in diphtheria and 
those of croup. In diphtheria, however, the sub-mucous 
tissue usually becomes more extensively involved, so that 
the false membrane is much less readily removed, The 
circulation also becomes so much interfered with that 
portions of the tissue lose their vitality, and large ash-colored 
sloughs are formed, which, after removal, leave a consider- 
able loss of substance." Again, on removing the membrane 
of croup, the mucous membrane remains smooth and 
uninjured, while in diphtheritic croup, on removing the 
exudation, the surface is ulcerated and gangrenous. Dr. A. 
W. Barclay,- however, remarks that " the fibrinous exudation, 
so unusual in inflammation of mucous membranes, is also 
apparently identical ; but as far as we know, the cause is 
different." 



DIPHTHERITIC CROUP. 255 

Dr. Morell Mackenzie ridicules the idea of supposing 
" that there are two kinds of pellicular inflammation of the 
larynx, one in which the cause is the diphtheritic poison, and 
the other in which the cause is some other undiscovered 
influence, is totally opposed to all probabilities ;" but, as was 
pointed out by the croup-diphtheria Committee of the Royal 
Medico-Chirurgical Society, " Membranous inflammation, 
confined to or chiefly affecting the larynx or trachea, may 
arise from a variety of causes, as follows : (a.) From the 
diphtheritic contagion ; {b.) by means of foul water, of foul 
air, or other agents, such as are commonly concerned in the 
generation or transmission of zymotic diseases ; (c.) as an 
accompaniment of measles, scarlatina or typhoid, independ- 
ently of any ascertainable exposure to the especial diphther- 
itic infection ; (d.) it is stated, on apparently conclusive 
evidence, that membranous inflammation of the larynx and 
trachea may be produced by various accidental sources of 
irritation — the inhalation of hot water or steam, the contact 
of acids, the pressure of a foreign body in the larynx, and a 
cut throat." 

The mode of death in the two diseases is strikingly 
different, though, as a matter of course, the termination of 
all cases when death results from apncea is identical. " In 
croup," as Dr. Prosser James points out, "the exudation 
endangers life, both by inducing spasmodic closure of the 
glottis and by mechanically impeding the entrance of air into 
the lungs ; the patient dies suffocated ; in diphtheria it is 
associated with intense depression of the vital powers, such 
as we see in malignant fevers, and speaks plainly of blood- 
poisoning ; the patient dies exhausted." 

Dr. Alfred Meadows, of London, concludes his essay on 
the identity of the two diseases by remarking, "At any rate, 
zve must admit that tJiey both are blood diseases" — which we 
concede without demur. Scarlatina and syphilis are both 
" blood diseases," but few would draw arguments in favor of 
the identity of these diseases from that fact. 

Another point of difference is the site of the disease 



256 DIPHTHERITIC CROUP. 

Diphtheritic croup, in the vast majority of cases, commences 
in the pharynx and extends thence to the air passages, while 
pseudo-membranous croup commences in the larynx, and, if 
it spreads at all, it extends to the trachea and bronchial 
tubes. In croup the earliest symptom is that of stridulous 
voice and respiration ; in diphtheria the uneasiness is first 
felt in the fauces. Dr. Hauner, of Munich, says that " true 
croup always commences in the larynx " — it would be more 
correct to say that it generally commences in the larynx, while 
diphtheritic croup generally commences in the pharynx. 

Dr. Morell Mackenzie says : " The fact is, that croup is a 
disease which commonly commences in the pharynx, and 
only in about 10 or 12 per cent, of cases originates in the 
larynx or trachea." In a large number of cases of pseudo- 
membranous croup, I observed little islands of exudation of 
a pearly lustre in the neighborhood of the glottis, but that 
appeared at the same time as the exudation in the larynx, 
and sometimes even later. Very seldom have I observed 
the pharyngeal exudation preceding the laryngeal, certainly 
not more than in five per cent, of the whole number. No 
one could confound the water-white of the croup exudation 
with the milk-white of the diphtheritic one. Dr. Mackenzie 
adds, " Difference Of site, moreover, in a constitutional 
disease, does not constitute a specific difference. Here the 
constitutional nature of pseudo-membranous croup is assumed 
to be the same in kind as the constitutional nature of diph- 
theritic croup — to me they seem to differ as much as 
croupous pneumonia differs from gangrene of the lungs. 

" My idea of the problem to be solved is, in fact, this: It 
must be admitted that the diphtheritic poison is capable of 
giving rise to a plastic inflammation of the larynx, apart 
from the existence of any similar affection of the pharynx. 
But there is good reason to believe that during epidemics of 
diphtheria, the cases in which this occurs are, in the highest 
degree, exceptional. If, therefore, it can be shown that in 
the practice of a general hospital the cases of plastic laryn- 
gitis, of uncertain origin, bear a large proportion to the total 



DIPHTHERITIC CROUP. 257 

number of cases of diphtheria, there will be a strong 
probability that the majority of the fqrmer cases are 
dependent upon some other cause than the diphtheritic 
poison " — (Diphtheria and Croup, by W. H. Lamb, M. B., 
and C. Hilton Fagge, M. D., " Guy's Hospital Reports," 

1877). 

True croup is most frequently caused by the sudden 
passage from warm to cold air, and is often occasioned by 
sleeping in very cold bed-chambers after having been all day 
in hot rooms. Diphtheritic croup is the manifestation in 
the larynx of a blood disease ; and whatever effect external 
cause may have in bringing about diphtheria in general, they 
have very little in producing the laryngeal variety. True 
croup almost invariably begins with catarrh and fever, and 
this in exact ratio with the severity of the local symptoms ; 
difficulty in swallowing is very rare, is always very slight 
when it does occur, and it is always dependent on the 
laryngeal affection. In diphtheria catarrh is rare, for the 
fetid sanies which flows from the nostrils and mouth can 
hardly be called catarrhal, and from the very inception signs 
of deep-seated constitutional mischief are evident ; sore 
throat and difficulty in swallowing precede the laryngeal 
affection. 

Dr. Edmonds, of St. Louis, points out that while "croup 
is bold, abrupt and, as it were, outspoken in manner and 
character, diphtheria is sneaking, insidious and undefined in 
its mode of approach," and this, so far as my experience 
extends, holds almost universally good. Dr. L. Fleischmann 
remarks that while croup most frequently affects the mucous 
membrane of the air passages, diphtheria frequently has 
" multilocular invasion," the fauces, nose, genitals, intestines 
and the skin being affected simultaneously. Again, the 
kidneys and intestines are normal in croup, while in the 
laryngeal form of diphtheria they are often involved. 

Dr. Hillier remarks, " It appears to me as impossible to 
maintain that croup is merely a local disease, as that 
pneumonia is merely local, or catarrh, both of which are 



258 DIPHTHERITIC CROUT. 

generally indications of a morbid constitutional state." 
Precisely so, croup and pneumonia are strictly analogous 
diseases, and the " morbid constitutional state " is, in both 
affections, dependent on the local disease. But that may 
be freely conceded without granting the identity of true 
croup and diphtheritic croup. 

Dr. Morell Mackenzie says, " It is true that in croup the 
general symptoms are not so severe as when the membrane 
is thrown out on an extensive portion of the pharynx. This 
fact admits of ready explanation, on the view that the septic 
symptoms are in part secondary to the local processes." But 
in diphtheritic croup, the septic symptoms precede the local 
process in the vast majority of cases, and I have rarely seen 
diphtheria attack the larynx in the first instance. Again 
Dr. Mackenzie says, " When the primary septic poisoning is 
powerful, the constitutional symptoms are, however, as 
marked in so-called " croup as in diphtheria." No other 
medical observer on either continent, so far as I know, has 
asserted that pseudo-membranous croup is accompanied or 
followed by constitutional symptoms similar to those which 
accompany diphtheritic croup, for, as Dr. Edmonds ably 
points out, " In diphtheria the diseased appearance in the 
larynx or trachea is simply the outcropping of a previous 
constitutional taint. The outcropping is not confined to the 
larynx or trachea, but may show itself in the nose, throat, 
eyes, ears, and even upon the cutaneous surface, wherever 
there may be the slightest break of integrity or denuding of 
surface." 

True croup, then, is a local inflammation of an exudative 
character accompanied by a purely inflammatory fever, while 
diphtheritic croup is originally a blood poisoning, and the 
laryngeal disease is what Hahnemann would call " a local 
manifestation " of that blood poisoning — hence, in a majority 
of cases of true croup the pharynx is healthy, or almost 
healthy, while in a majority of cases of diphtheritic croup 
the pharynx is diseased. 

Another important distinction between the two diseases 



DIPHTHERITIC CROUP. 259 

is, that while true croup is a sthenic inflammation, diphther- 
itic croup is accompanied by fever of an adynamic type. In 
opposition to this, Dr. Morell Mackenzie asserts that " cases 
of sthenic croup are very rarely met with, and the same 
remark applies to diphtheria." All the text-books, all the 
observers of both continents, describe the fever of pseudo- 
membranous croup as being sthenic, and I venture to say 
that Dr. Mackenzie stands alone in his position, and though 
he says that " distinctions based upon differences of type in 
the two diseases can have no weight," it is quite certain that 
all diagnosis depends upon the detection of just such 
"differences of type." While, then, true croup commences 
with inflammatory fever of a very pronounced type, diph- 
theritic croup is accompanied by fever of a typhoid or 
adynamic type. 

Another important difference is that in croup the cervical 
lymphatic glands are not swollen, while in diphtheritic croup 
the cervical glands are inflamed and consequently enlarged. 
Dr. Mackenzie admits that " the cervical glands are not often 
affected in croup, because the mucous membrane of the 
larynx has no communication with the superficial cervical 
glands ; on the other hand, as stated above, there is an 
elaborate connection between the pharynx and the lymphatic 
glands," and he quotes Luschka's ingenious explanation : 
"Whilst the lymphatics of the mucous membrane of the 
soft palate, of the tonsils and of the back of the pharynx 
have very free communications with the numerous glands 
below the angle of the jaw, the absorbent vessels of the 
mucous membrane of the larynx and trachea are conveyed 
only to the solitary gland just below the greater horn of the 
hyoid bone, and the small gland at the side of the trachea." 
The fact is, that in pseudo-membranous croup the cervical 
glands are swollen, especially those at the outer border of 
the sterno-mastoid muscle ; but, as Dr. L. Fleischmann accu- 
rately points out, in croup there is swelling of the glands, 
but almost never suppuration of fetid character, while in 
diphtheria suppuration of the glands is of frequent occur- 
rence. 



26o DIPHTHERITIC CROUP. 

Another point of difference, formerly looked upon as all 
but conclusive, and still much relied upon by excellent 
observers, is that while albuminuria is present in diphtheritic 
croup, it is not present in pseudo-membranous croup. Even 
as late as 1880, Dr. Henry Hartshorne, of Philadelphia, affirms 
that " croup is not followed by albuminaria," and Dr. Squire 
states that in drawing the diagnostic lines between the two 
morbid states, u the presence of albumen in the urine is 
conclusive" Oirthe other hand, Dr. Morell Mackenzie affirms 
that " in croup albuminuria is often found." Dr. Hillier says 
that "albumen has been found in the urine of patients with 
croup.;" while Dr. Alfred Meadows, of London, states that 
" in mild cases of diphtheria there is often no albuminuria, 
while in severe cases of croup it is not unfrequently present." 
But the force of all these observations, undoubtedly correct 
as they certainly are, is broken by the fact that the elaborate 
researches carried on under the auspices of the Royal Medico- 
Chirurgical Society, of London, conclusively prove that 
albuminuria occurs in cases of laryngitis in which no 
membrane is formed — that is, in simple laryngitis which is 
neither croupous nor diphtheritic. The conclusion seems to 
be that albuminuria is relatively less frequent in pseudo- 
membranous croup than in diphtheritic croup, but that as it 
also occurs in phases of laryngeal disease which belong to 
neither of these classes, this criterion must be looked upon 
as being indecisive. 

One of the principal clinical differences is that while 
paralysis occurs after diphtheritic croup, it does not occur in 
true croup. Dr. Squire says that " paralysis of some of the 
muscles of vocalization, deglutition or of motion, is equally 
distinctive of diphtheria ;" Dr. L. Fleischmann states that 
in croup "paralysis never occurs," while in diphtheria, "even 
in mild cases, severe nervous disturbances are common ;" and 
J. Solis Cohen gives it as a chief point of difference : " In 
croup no secondary paralysis ; in diphtheria secondary 
paralysis is frequent." 

On the other hand, Dr. Morell Mackenzie says that 



DIPHTHERITIC CROUP. 261 

"paralysis is rare in croup, because nearly all the cases 
terminate fatally, but it is occasionally met with in those 
that survive ;" I have never met with paralysis after true 
croup, and no writer on the disease has ever mentioned such 
a thing, and Dr. Mackenzie is describing cases which nine- 
teen medical men out of twenty would call diphtheritic 
croup. Dr. Hillier remarks : " Even when epidemics of 
diphtheria prevailed in former times, the nervous sequelae 
were not noted ; we have no record of these phenomena till 
a comparatively recent period. It is quite probable that 
even if symptoms of disordered innervation had followed 
sporadic croup in as large a proportion of cases as they 
follow epidemic diphtheria, they would not have been 
connected with the previous illness," but some of the Spanish 
and Sicilian writers describe nervous phenomena following 
garrotilla, and it would be strange, indeed, if observers 
failed to connect disordered innervation with true croup in 
the purely hypothetical case stated by Dr. Hillier. Dr. 
Alfred Meadows observes : " Paralysis is frequently absent, 
even in rather severe cases of diphtheria. In France it is 
said that paralysis is present in at least one-third of the cases, 
while in England it does not occur more frequently than in 
ten per cent, of the cases ; therefore, it might be argued 
that at least in those cases where this symptom is absent, 
there is nothing essentially distinguishing it from croup." 
Dr. Meadows does not affirm that paralysis has ever been 
observed to follow true croup, and in cases of diphtheritic 
croup, when paralysis is absent, other diagnostic marks, 
equally conclusive, are present. Another writer, who upholds 
the doctrine of the unity of these diseases, candidly admits 
that "sporadic cases" — by which he means cases of true 
croup — are rarely followed by paralysis or albuminuria, and 
this is the conclusion of a vast number of careful and impar- 
tial observers. 

True croup is non-epidemic, non-contagious and non- 
inoculable, while diphtheritic croup— in common with all 
manifestations of diphtheria — is epidemic, contagious and 
inoculable. 



262 DIPHTHERITIC CROUP. 

In 1879 tne R°yal Medico-Chirurgical Society of London 
appointed a committee to examine the relations existing 
between croup and diphtheria, and in the very interesting 
report the following passages bear on this question : 
" Membranous inflammation, chiefly of the larynx and 
trachea, to which the name ' membranous croup ' would 
commonly be applied, may be imparted by an influence, 
epidemic or of other sort, which in other persons has 
produced pharyngeal diphtheria. And, conversely, a person 
suffering with the membranous affection, chiefly of the air- 
passages, such as would commonly be termed membranous 
croup, may communicate to another a membranous condition, 
limited to the pharynx and tonsils, which will be commonly 
regarded as diphtheritic." Gerhardt asserts that he has, 
himself, " described a sporadic case which proved contagious," 
which may well be the case if the sporadic case was 
diphtheritic. Dr. Meadows observes, " we know that croup 
does sometimes occur epidemically, and if it be not 
contagious so neither is it certain that diphtheria, when it 
attacks a number of persons in the same house or locality, 
is really communicated ; for the fact may be due to the 
exposure of those affected to the same influence and at the 
same time." To this it is sufficient to reply that it is 
quite certain that diphtheria is contagious, but no sufficient 
evidence has yet been adduced to prove that croup possesses 
the same quality, and the onus probandi lies with those who 
assert that it is contagious. 

Dr. Edmonds says, " Diphtheria is a zymotic, constitutional 
blood disease, is in many instances believed to be contagious, 
is undoubtedly inoculable by application of matter from a 
diphtheritic part to the mucous or denuded surface of a 
healthy subject." Dr. Charles West points out that while 
" croup is influenced by climate and season, is endemic in 
some localities, but not epidemic nor contagious, diphtheria 
is independent of climate or season, contagious and often 
epidemic." Dr. L. Fleishmann observes that while " in croup 
there is no infection of the blood, with corresponding 



DIPHTHERITIC CROUP. 263 

symptoms depending thereon, in diphtheria there is infection 
of the blood and fatty degeneration of the striped, muscular 
tissue, especially that of the heart, and he adds that while 
croup is not inoculable, diphtheria is inoculable. Hirschel's 
experience is that while diphtheria is contagious and mostly 
epidemic, croup is not contagious, and is mostly sporadic. 

Steiner's views on this point are valuable, and he concludes 
that " the attempt to distinguish croup and diphtheria as 
two entirely distinct diseases has been unsuccessful, both 
from an anatomical and from a clinical standpoint," yet he 
admits that " primary true croup is not a contagions disease, 
although it is so regarded by Bohn, Gerhardt and others. 
Diphtheritic croup, however, possesses this quality in a high 
degree." Dr. Hillier, too, asserts that " epidemic croup" is 
always diphtheria — which is precisely the conclusion of the 
present writer. 

True croup is a disease of cold weather ; diphtheritic 
croup ravages in all weathers and in all seasons. Croup is 
caused almost solely by climatic influences, although at times 
it is endemic ; diphtheria is favored by everything which 
promotes the growth of spores, as crowded dwellings, 
personal uncleanliness, and so forth. 

True croup rarely occurs more than once in the same 
patient, but it is quite common for children to have several 
attacks of diphtheria. As to age, true croup appears much 
earlier than diphtheritic croup. True croup is almost 
peculiar to children ; adults as well as children are the 
victims of diphtheritic croup. Dr. Alfred Meadows says : 
" In regard to croup seldom or never attacking adults, while 
diphtheria frequently does, this can hardly be relied upon, 
because the same may almost be said of scarlatina." Adults 
are seldom attacked with scarlatina, simply because they 
have passed through that ordeal in youth ; would Dr. 
Meadows affirm that adults are free from croup because they 
have had it in youth ? Dr. Hillier ingeniously argues that 
" when diseases become epidemic they are more liable to 
attack adults, who escape when the disease is only sporadic," 



264 DIPHTHERITIC CROUP. 

but this is a theory as yet unsupported by facts and figures. 

I have never observed in true croup the scarlatiniform 
eruption so often seen in diphtheritic croup, and Dr. Lyon, 
of Connecticut, points out that in croup pseudo-membranes 
of the skin are never observed, while in diphtheria pseudo- 
membranes of the skin are occasionally observed. 

Dr. Ludlam, of Chicago, writes as follows : " The dyspnoea 
in croup is paroxysmal, and invariably worse at night. There 
is a true spasm of the laryngeal and tracheal muscular 
fibres. At intervals the patient breathes almost naturally. 
In a few moments, especially if permitted to sleep, he is in 
a fit of suffocation again, which, by-and-by, alternates with 
relative repose. The ease and freedom of the respiratory 
movements in diphtheria vary considerably at intervals, but 
the intervals occur irregularly during the day as well as at 
night, and the relief afforded by them is less marked than in 
the case of croup. In true croup a trembling, vibratory 
sound may often be heard on auscultation, denoting the 
presence of floating false membrane, but the characteristic 
auscultatory indication of diphtheritic croup is a soft gurg- 
ling sound, similar to the cavernous rale of phthisis. Dr. 
J. Solis Cohen remarks that in croup there is no weakening 
of the heart's action ; the pulse frequently strong and hard, 
while in diphtheria there is marked weakening of the heart's 
action ; pulse never strong and hard, even though rapid 
and full. 

Finally, it is a matter of frequent observation that while 
in croup the general health is rapidly reestablished, a 
complete recovery, without sequelae, following the cure of 
the local disease, in diphtheritic croup the convalescence is 
remarkably slow and tedious, with annoying sequelae lasting 
for months and even years. 

Monti considers croupous laryngitis to be a separate 
disease, independent of diphtheria, but he considered that 
it may arise from diphtheria, and Dr. J. Solis Cohen admits 
that there is no actual anatomical distinction between croup 
and diphtheria, though he contends that the clinical differ- 



DIPHTHERITIC CROUP. 265 

ences are numerous and important. Dr. Charles West, a 
most distinguished writer, has come to the conclusion, which 
he long hesitated to adopt, " that what differences soever 
exist between croup and diphtheria, they must be sought 
elsewhere than in the pathological changes observable in the 
respiratory organs." Nevertheless, he adds, " If we extend 
our inquiry beyond the mere changes wrought in the respir- 
atory organs, the differences between croup and diphtheria 
at once become apparent ; and the affinities of the latter 
disease are seen to be to the class of blood diseases, rather 
than to that of purely local inflammations to which croup 
belongs." 

The Committee of the Royal Medico-Chirurgical Society, 
of London, came to the conclusion that "these two diseases 
are identical," but, strange to say, the. discussion on the 
subject subject did not lead the members to harmonious 
conclusions, for not very many English practitioners would 
say with Dr. Hillier, " I can detect no distinction between 
membranous croup and laryngeal diphtheria." Pseudo- 
membranous croup and diphtheritic croup are not identical 
diseases, but they certainly have much in common, and, as 
Dr. West puts it, " the sameness of the anatomical changes 
produced by two diseases does not suffice to establish their 
identity." He adds, "The practitioner of midwifery knows 
that simple puerperal metritis and puerperal fever are 
diseases which differ widely in their symptoms, their course, 
their danger, and the degree in which they are amenable to 
remedies, though in both, when they terminate fatally, 
precisely the same alterations in the womb are discovered." 

It is impossible to confound typical cases of true croup 
with typical cases of diphtheritic croup, and only occasion- 
ally need there be any doubt as to the diagnosis. At 
the same time, I concede that since the. advent of diph- 
theria in Canada (1858) I have observed an increasing 
disposition in pseudo-membranous croup to take on a 
kind of diphtheritic aspect, but the same thing has been 
noticed with all diseases of the mouth and fauces, and one 



266 DIPHTHERITIC CROUP. 

of the very strongest proofs of the essential dissimilarity of 
the two diseases is that given by Dr. Henry Hartshorne: "A 
table is given in Meigs and Pepper's treatise on the Diseases 
of Children, which shows that after diphtheria had, about 
i860, become recognized as, at that time, a new disease in 
Philadelphia, the mortality from it added, for several 
successive years, more than 300 to the deaths in each year 
in that city, while the deaths from croup continued to 
number annually, as before, from 200 to over 400." 

The prognosis is very bad. The Lancet Sanitary Commis- 
sion-Report on diphtheria states that " symptoms of croupal 
suffocation soon supervene from the extension of the diph- 
theritic formation to the air passages, and when this is the 
case, recovery is exceptional." Dr. Churchill says that " when 
the false membranes extend into the larynx and trachea we 
shall have croup with all its danger." Condie remarks that 
" when the disease extends to the larynx, it is very frequently 
fatal." According to Greenhow, " comparatively few persons 
recover when diphtheria extends downwards into the air 
passages ; but sometimes moulds of the larynx, trachea and 
bronchial tubes, to their third or fourth division ; and in a 
case seen by Mr. Thompson, of Launceston, to the fifth 
division, are expectorated with immediate, though too often 
only temporary, relief to the patient, who frequently succumbs 
from a renewal of the exudation." 

Dr. J. F. Meigs says, " If it extend into the air passages 
very soon after the invasion, it may cause death within a few 
days." Sir George Duncan Gibb thinks that "the prognosis 
of this form (laryngeal diphtheria) is extremely unfavorable." 
Dr. Bernhard Baehr says that " the extension of the diph- 
theritic process to the larynx and lungs is almost always 
fatal." Maunsell affirms that " in very acute cases the false 
membrane will spread into the larynx, if not early arrested ; 
and in some instances its formation seems to occur almost 
simultaneously in the air passages and on the pharynx, the 
croupy symptoms appearing to co-exist with the appearance 
of lymph on the fauces ; such an event we need hardly say 
must be almost necessarily fatal." 



DIPHTHERITIC CROUP. 267 

Vogel states that " in diphtheritic croup, especially after 
measles, a recovery now and then takes place, upon which 
the treatment, as we will see further on, has no very remark- 
able influence. Where collapse, cyanosis and an uncountable 
pulse have supervened, there speedy death may be prognos- 
ticated with certainty." Oehme says that diphtheria of 
the larynx has proved, in the greater number of cases, a 
fatal disease. Some physicians have not hesitated to say 
they have never cured a case." Jacobi says that " diphtheria 
of the larynx, whether it be of primary origin or the result 
of extension from the fauces, is nearly always fatal. In 
severe epidemics the mortality is 95 per cent. 

In the year i860, I wrote an essay on diphtheritic croup 
in which I expressed myself as follows in regard to the 
prognosis: ''But little need be said as to the prognosis of 
this disease ; it is bad, very bad, and I do not believe that 
more than one-half of the cases recover, even under the best 
homoeopathic treatment. The cause of this is evident, for 
before the larynx is attacked, the patient has usually been 
depressed and worn out by the primary disease, and is quite 
unfit to contend with such a formidable foe. I find that the 
best plan is to explain the state of matters frankly to the 
parents on being called to the case, and here, as in many 
other circumstances of life, ' honesty is the best policy. " 
The younger the child the greater the danger of diphtheritic 
croup coming on in the course of diphtheria. Again, the 
younger the child the greater the danger when laryngeal 
diphtheria does make its ominous appearance, and this 
increased danger arises from the small size of the larynx in 
infancy. Romberg states that " Richerand was the first to 
determine that the larynx and glottis, which in early life are 
very small, suddenly increase at the period of puberty, in 
the male sex in the proportion of 5.10, in females of 5.7. 
Schlemm has confirmed this observation, and has added a 
few details : thus he found the rima glottidis of a child of 
twelve years one and a half to two lines longer than that of a 
child of three years, and in the latter it was three-quarters of a 



268 DIPHTHERITIC CROUP. 

line longer than in a child of nine months." When the 
larynx, trachea and bronchial tubes are lined with diphther- 
itic membrane the case is all but hopeless, though strange 
cures take place, even when the patient seems to be in 
extremis, and I particularly remember one notable case in 
which, under the influence of Kali bichromicum, the patient 
expectorated a cast of the larynx, trachea and larger bron- 
chial tubes with immediate and permanent relief. 

In the first volume of Marcy and Hunt's Practice, page 
763, we read that "a persistent use of the proper homoeo- 
pathic remedies will cure nearly all cases of this' malady" 
(diphtheria), and to this somewhat startling statement they 
add that " we have treated more than 200 cases, including 
many of the malignant type, and our losses have not been 
one per cent." It is not stated how many of these two 
hundred cases were laryngeal in their nature, though one 
would like very much to know, but I imagine that no experi- 
enced physician would make these statements in connection 
with diphtheritic croup. 

Opinions differ very much as to the value of tracheotomy 
in diphtheritic croup, and till quite recently Dr. Slade was 
almost the only writer of eminence who spoke favorably of 
it. He says : " Without going into a history of tracheotomy, 
or a recapitulation of the arguments on the one side or the 
other, we most unhesitatingly say that, under the circum- 
stances above mentioned, this operation is a resource which 
we are in duty bound to employ for the safety of our patients, 
and in view of what experience teaches us is otherwise 
certain death. It is not by so doing that we increase his 
chances for life solely, but in case of an unfavorable termi- 
nation we render his last moments less distressing." Dr. 
Squire, who sharply distinguishes pseudo-membranous croup 
from diphtheritic croup, writes as follows : " Tracheotomy 
should be performed whenever the increasing recession of 
the softer parts shows that the cause of obstruction to the 
entrance of air is increasing. In the greater number of cases, 
if the local indication of the glottis and larynx do not suffice 



DIPHTHERITIC CROUP. 269 

to obviate the danger, tracheotomy, performed early, is much 
more likely to be successful than after the, use of remedies 
that in any way impair the vital powers. A delay that 
admits of secretions accumulating in the bronchi is dangerous, 
and extension of the disease to the lung is the one insur- 
mountable obstacle to success. Where the effects of the 
obstruction are more suddenly induced, tracheotomy, 
performed at the very last moment of apparent life, may 
save it. No degree of severity in the general disease should 
interfere with this means of arresting threatened death from 
asphyxia, unless the presence of some other complication, 
necessarily fatal, can be demonstrated. I recently saw a case 
in consultation with Mr. Adams, in which, had it occurred 
at the commencement of the epidemic instead of towards the 
end, I should have decided against tracheotomy, concluding 
that it must end fatally, although unconsciousness had set 
in before commencing to operate ; the child, six years old, 
recovered." 

Professor Rosen, of Tubingen, reports forty-two cases of 
tracheotomy in diphtheritic croup, with nineteen recoveries. 
In six of the cases asphyxia had advanced too far before the 
operation, and of the subsequent deaths, one took place from 
pneumonia, fifteen days after, and one from albuminuria in 
the third week. Professor George Buchanan, of Glasgow, 
asserts that in every eight cases of tracheotomy performed on 
children practically moribund from suffocative membranous 
effusion into the trachea, he has saved three. The Professor 
reports 50 cases of tracheotomy in the British Medical Journal 
(1880), of which 17 were classed as croup and 33 as diph- 
theria, the latter including all those forms in which there 
was a distinct deposit of white false membrane on the 
tonsils, palate, or fauces. Of the 17 croup patients, 10 died, 
1 immediately after the operation, the others in from 3 hours 
to 4 days. Of the 33 diphtheria patients there was a 
mortality of 21, 1 of whom also died immediately after the 
operation, the others in from 6 hours to 1 3 days. 

Dr. W. H. Day, who, like Dr. Squire, holds that the two 



270 DIPHTHERITIC CROUP: 

diseases are totally distinct, yet reports the following 
deeply interesting cases : " Two interesting cases of success- 
ful tracheotomy, in the last stage of diphtheria, were brought 
before the Clinical Society by Mr. George Lawson and Mr. 
Pugin Thornton (Feb. 28, 1879). Two cases of diphtheritic 
laryngitis have been recorded, in which recovery also 
followed tracheotomy. The first case was that of a boy six 
years of age, who was admitted into the Middlesex Hospital 
under the care of Dr. Coupland, May 30, 1880. The success- 
ful issue was owing to the operation having been performed 
at an early period of the disease before much false membrane 
had formed. 

"The second case was'also that of a boy seven years of 
age, who was admitted into the Children's Hospital under 
the care of Dr. Gee, on September 15, 1879. Recovery 
followed quickly, notwithstanding the extreme dyspnoea at 
the time of operation, and the large quantity of membranous 
casts expelled through the tube afterwards." 

Steiner thinks that " when the larynx becomes implicated 
the various external and internal remedies, which have 
already been referred to under the diseases of the larynx* 
such as emetics, must be employed, and, failing any benefit 
from these, there remains only the operation of tracheotomy." 
Dr. Jacobi, the most persistent advocate of the unity of 
croup and diphtheria on this continent, writes as follows : 
" In regard to tracheotomy, that last resort in croup, I 
cannot refrain from stating that, in proportion to the increas- 
ing severity of the diphtheritic epidemics, the results of 
tracheotomy in my hands and in those of others, have grown 
worse and worse. Of sixty-seven tracheotomies which I 
published twelve years ago, twenty per cent, recovered ; 
about two hundred tracheotomies performed by me since 
that time brought down the percentage of recoveries to 
such a low figure that only the utter impossibility of 
witnessing a child's dying from asphyxia has goaded me on 
to the performance of tracheotomy. I here add that I do 
not wish it to be inferred that I have changed my views 



DIPHTHERITIC CROUP. 2J\ 

concerning the indications for the operation of tracheotomy, 
as Boehme seems to believe. On the contrary, in spite of 
numerous ill successes, I hold to the principle that where 
there is danger of suffocation through stenosis of the larynx, 
there is the indication for tracheotomy. Where there is no 
stenosis, I am glad not to operate. The results are not so 
bad, after all, when we remember that only such cases are 
operated upon which would be sure to die, if the operation 
were not performed." 

One would like to know how many of the patients treated 
by Buchanan, Squire and others had true diphtheria with 
blood-poisoning, and how many had a purely local laryngitis 
with exudation, but lacking the blood-poisoning which is 
almost of the essence of diphtheria. On this point the 
remarks of Dr. Alfred Meadows are of the greatest value, 
the more so as that excellent writer believes croup and 
diphtheria to be identical diseases. After stating that 
Trousseau believes that half the operations performed will 
be successful, always provided that tracheotomy takes place 
when the chances of cure are possible, he adds : " This 
restriction is important ; for if the diphtheritic infection is 
thoroughly rooted in the system, if the skin, and particularly 
the cavities of the nose, are invaded by this special phleg- 
masia, as is often the case in France ; if the quickness of the 
pulse, delirium and prostration indicate a profound poison ; 
and if the danger is rather in the general state than in the 
local lesion of the larynx or trachea, certainly the operation 
should not be tried, for it is invariably fatal." Dr. Meadows 
further adds, " when, however, the local lesion constitutes 
the principal danger of the disease, no matter to what degree 
asphyxia has arrived, even when the child seems to have 
only a few moments to live, tracheotomy very often succeeds" 
— and tliis " local lesion" is correctly styled pseudo-membra- 
nous croup. 

Dr. Morrell Mackenzie thinks that " considering the 
enormous mortality of laryngeal diphtheria, even the most 
unfavorable figures prove that in such cases tracheotomy is 



272 DIPHTHERITIC CROUP. 

not only justifiable, but that it is a positive duty ;" yet 
Mackenzie gives a table of " operations for croup," in the 
Hopital des Enfants Malades, showing that whereas in 185 1 
the cures were 1 in 2.21, in 1875 the cures were 1 in 4.76 
Mackenzie gives a similar table for the Hopital Sainte 
Eugenie, showing that while the cures in 1854 were 1 in 4.50, 
in 1876 the proportion of cures was only 1 in 8.31. M. 
Mazard attributes this steady increase in the mortality, after 
tracheotomy, " partly to the progressive extension of the 
operation to more and more hopeless cases, and partly to 
the more malignant character of the disease in Paris during 
recent years ;" but I incline to attribute it to the fact that 
in the earlier years true croup was chiefly present, while in 
the later years there was much more diphtheria. 

Oertel writes : " According to the notes of Professor von 
Nussbaum, which he has most kindly communicated to me, 
of twelve undoubtedly diphtheritic children, whose ages 
varied between three and four, and on whom he ' had 
performed tracheotomy, all died ; and only two older ones, 
whose ages were twelve and fourteen, survived, but in them 
the whole course of the disease had shown itself much more 
favorable." Dr. Helmuth remarks : " The results after the 
operation of tracheotomy in croup are not very satisfactory, 
and in diphtheria they are, as far as my observation, reading 
and experience extend, still less so. I can call to mind but 
four cases in which the operation has been performed in 
diphtheria, one of which is said to have proved successful. 
None of these cases, however, occurring in my own practice, 
and circumstances occurring which have, prevented actual 
inquiry in reference to the minutiae of each, I am not 
prepared to offer any remarks upon them. But in the cases 
which I have treated, and which have succumbed to the 
diphtheritic poison, I have not witnessed one which would 
justify the interference of the surgeon." Dr. A. L. Voss of 
New York says : " It is worthy of remark that I have not 
heard of a successful operation in New York during the year 
1859, famous for diphtheria. Tracheotomy is a dernier 



DIPHTHERITIC CROUP. 273 

resort in diphtheria. I have no confidence in it in this 
disease. Diphtheria is an affection of which the local lesion 
is the least important part. Its erratic nature, its proneness 
to reappear upon a neighboring or remote surface, argues 
very strongly against the promise of success by local means 
alone. If you remove the plastic deposit from the trachea by 
a surgical operation, a few hours later will be apt to reveal 
symptoms of a like formation within the larynx or the 
bronchi. Possibly the operation may be serviceable in croup, 
but not in diphtheria." 

In almost all the statistics adduced to prove the value of 
tracheotomy in diphtheritic croup, the comparatively 
manageable pseudo-membranous croup is mingled with the 
very unmanageable diphtheritic croup, so that little reliance 
can be placed on them. For example, Dr. Morell Mackenzie 
writes : " At the Hospital for Sick Children in the twelve 
years, 1864 to 1876, sixty cases of croup and diphtheria were 
operated on. Of these, thirteen, or 21.6 per cent., were 
successful." One wants to know how many of these cases 
were croup, and how many were diphtheria, for the mortality 
is much more than trebled by the presence of the diphtheritic 
blood-poisoning, and no experienced physician expects to 
save 21 out of every 100 cases of genuine diphtheritic croup. 
And even when some little attempt is made to discriminate 
between the two diseases, the diagnosis is so superficial that 
it commands no respect. Thus of the 50 tracheotomy cases 
of' Buchanan's, already alluded to, 17 were classed as croup 
and 33 as diphtheria," the latter including all those forms in 
which there was. a distinct deposit of white false membrane 
on the tonsils, palate and fauces." Of the 17 croup cases 10 
died, of the 33 so-called diphtheritic ones 21 died — not a 
very great difference in the mortality. And it is not 
sufficient for diagnostic purposes to tell us that there was a 
" distinct deposit of white false membrane on the tonsils, 
palate or fauces," for that is often seen in pseudo-membranous 
croup, but one wants to know the history of these cases, 
whether or not diphtheritic blood-poisoning was present, and 



274 DIPHTHERITIC CROUP. 

till that is done, I will ponder the words of Vogel, " We 
really have few diphtheritic, but mostly genuine fibrinous 
croup patieiits." 

Commenting on von Nussbaum's cases, already alluded to, 
Oertel writes as follows, and his weighty words must 
command the respectful attention of all physicians of 
experience : " If now, figures are to be found in literature 
which furnish much more favorable statistics of tracheotomy 
in diphtheria, these data cannot be considered as trustworthy 
so long as the boundaries between croup and diphtheria are 
not precisely defined ; in the cases referred to above the 
diagnosis of diphtheria was established beyond a doubt. It 
is very evident that the issue of such an operation should be 
wholly different if the case is one of a simple exudative 
process in the respiratory mucous membrane, following a 
local inflammation of high degree, and not one in which the 
local trouble is the primary localization of a general 
infectious disease." 

In diphtheritic croup, as a very general thing, the 
condition of the patient forbids any surgical interference 
whatever, and it is only in rare cases like those of Squire and 
von Nussbaum that it should be even thought of. In croup 
you have to do with a disease which is local, or at least very 
largely so, and here tracheotomy is admissible in certain 
cases, but in diphtheritic croup you have to do with a patient 
who, in addition to a severe local disease, is suffering from a 
violent blood-poisoning,, and here the chances of success, or 
even of palliation are, save in very rare cases, illusory in the 
extreme. 

The bed-chamber must be lofty and well-ventilated. The 
air must be both warm and moist, and draughts must be 
carefully avoided. The only prophylactic treatment which 
is of any avail is the prompt removal of children from the 
infected locality. That must be done at once, for here no 
chemical agent is of any use, and some of them, notably 
chloride of lime, positively invite the disease to the larynx. 
The food must be nourishing and liquid. Milk very slightly 



DIPHTHERITIC CROUP. 275 

thickened with arrow-root is excellent, and well made beef- 
tea is always in place. But I have had the best results from 
oyster-soup, giving only the thin part. Both English and 
German writers give stimulants in large doses, but I have 
rarely seen any good from them, and it seems to me that the 
dose of which Oertel speaks — an ounce or an ounce and a 
half of Cognac in twenty-four hours to children only three 
or four years old — is excessively large. In the matter of 
after-treatment, it is of importance to see that the child does 
not over-exert the organ of voice. Rest, nourishing food, 
fresh air are indispensable, and, when seasonable, sea-air is the 
best of all restoratives. 

Physicians of our school differ very much as to the value 
of Kali Bichromicum in laryngeal diphtheria. Dr. Ludlam 
thinks that it is almost specific to the diphtheritic membranes 
found upon the respiratory epithelial surface, and this is 
endorsed by Drs. Marcy and Hunt, while Dr. Lord, of 
Chicago, emphatically says that it is the remedy. Dr. A. E. 
Small, of Chicago, says ; " I have found the 3d attenuation 
of this remedy of the greatest value in diphtheritic croup 
when administered early after the manifestation of the 
difficulty. I have given it when the following symptoms 
were present : hoarse, croupy cough ; sore throat ; the 
appearance of livid patches, indicative of false membrane, at 
the posterior of the fauces ; great prostration and laborious 
breathing.'.' On the other hand, Dr. Hughes, of London, 
has used it " without the least benefit," and in a later work, 
he adds that "In laryngeal diphtheria it does all that 
medicine can do, which, unhappily, is not much," and Dr. 
Laurie seems to consider it a kind of forlorn hope to be. 
given if Bromine should fail ; the Bromine have been given 
when Iodine failed. Dr. Bernhard Baehr, while admitting 
that " the symptoms of this drug undoubtedly point to its 
use in diphtheria, and assign to it an important rank among 
the remedies for this disease," remarks that " striking 
therapeutic results have not yet been attained with it." In 
this matter I entirely and cordially agree with Dr. Ludlam, 



276 DIPHTHERITIC CROUP. 

and have no hesitation in assigning to Bichromate of potash 
the first place in the brigade of remedies with which we 
combat diphtheritic croup. Dr. Ludlam's remarks are 
worthy of the most careful perusal : 

" I. This remedy seems especially appropriate to pseudo- 
membranous lesions of a diphtheritic nature affecting the 
respiratory mucous surfaces, as the nares, the superior 
portion of the pharynx, the larynx, the trachea, and the 
bronchial tubes, even down to their ultimate ramifications. 

" 2. Where the deposit is of firmer texture, more apt to be 
developed into casts which are cartilaginous or pearly in 
in appearance, elastic, fibrinous, and more securely attached 
to the subjacent integument. 

" 3. It is indicated in all those cases where a transfer of 
the local disorder to the larynx or trachea impends, as shown 
by soreness of the larynx when pressed upon from before 
backwards, aphonia, croupy inspiration or cough, and a 
desire on the part of the patient to lie with the head thrown 
backwards in order to open the glottis. 

" 4. It may also be given with excellent results in case the 
tonsils are almost or quite enveloped by a thick and well- 
organized deposit, and in which at the same time the patient 
has an almost incessant cough. 

" 5. Also where, with the foregoing symptoms, there is 
an evident tendency to ulceration and deposit upon remote 
mucous membranes, as, for example, those of the uterine 
system. In my own experience, the Bichromate is almost a 
specific to diphtheritic formations upon the free uterine, and 
to those found upon the respiratory epithelial surfaces. 

" 6. Since in all these cases the putrid symptoms are less 
marked than in the pharyngeal and alimentary diphtheria, 
you should take the hint to cease the employment of 
Bichromate when these symptoms ensue. The Iodine of 
arsenic, Nitric acid, or Carbo-vegetabilis are much more 
decidedly indicated for the relief of such a condition. " 

The diphtheritic croup in which this remedy is indicated, 
is generally an extension from the fauces, simply because 



DIPHTHERITIC CROUP. 2JJ 

that is the usual development of the disease, but it is the 
first remedy to be thought of when the disease originates in 
the larynx in the first place, and extends thence to the 
fauces. The pseudo-membrane lining the fauces and 
extending to the air passages is whitish-yellow or of an 
ashy-grey hue, and the fetor is quite marked. The croupous 
cough occurs in paroxysms, especially worse from two Xo 
three o'clock in the morning, and this cough occasionally 
expels viscid mucus, which may be drawn out into long 
strings, and the same tough and stringy discharge occasion- 
ally appears in the nostrils, forming masses of partially-dried 
mucus, or there may be a thick, dark, bloody discharge from 
the nostrils. The tongue is raw, red and shining, or covered 
with a brownish-yellow coating, and the parotid .and sub- 
maxillary glands are distinctly swollen. Upon deglutition, 
the pain shoots up the ear and to the neck of the affected 
side. The patient is very weak, and has a cachectic look. 

Dr. Lord, of Chicago, advises the administration of this 
remedy by inhalation. The following is an extract from his 
report of a very severe case in which the remedy caused an 
aggravation, even when given in moderate doses : " When 
the Bichromate was given at intervals of an hour or more, 
the patient uniformly got worse. The cough was almost 
constant, except in the night when asleep. It ran up from 
a slight hacking to suffocation, which was only prevented by 
a means which I have purposely omitted to mention that I 
might direct your attention more particularly to it. After 
the twentieth day, when the cough became dry, and the 
respiration whistling, and when suffocation seemed immi- 
nent, inhalations of the Bichromate were used with prompt 
relief ; of course it Was only temporary, but it was a respite. 
But for it death must have ensued. It did not fail in a 
single instance of easing the breathing and loosening the 
cough, and ejection of membrane or large quantities of 
stringy mucus followed. The method was simple. Two or 
three grains of Bichr. 2 were put into a small tin teapot and 
half a teacup of hot water poured on. The vapor passing 



278 DIPHTHERITIC CROUP. 

from the spout was inhaled. I do not think that any 
medicines given in this case but the Arsenic and Bichromate 
had any good effect. I was so well satisfied of this that in 
all subsequent cases I have trusted entirely to the Bichro- 
mate as the specific remedy, and have had no reason to 
repent it. Other remedies may be required, but that is the 
remedy." — {Illinois State Horn. Trans., 1862.) 

Dr. Hughes says: "I think that Dr. Neidhardt's sugges- 
tion is very good, that it is necessary to attack the poison in 
the blood, even while, by the medicines specifically affecting 
the air passages, you are combating its dangerous local 
manifestation. He usually administers the Bichromate of 
potash (1st trit.) in alternation with his Chloride of lime. 
He has recorded two instances in which this treatment 
proved successful." To me, cases in which alternated remedies 
were used are as if they never had been recorded. This 
remedy seems to act best in the 2d or 3d decimal tritura- 
tions, a small powder in half a cup of water, of which a 
teaspoonful is to be given every hour or oftener. The 
remedy should be given by inhalation at the same time. 

All who have used Iodine consider that it is best indicated 
in the early stage of diphtheria when much glandular 
irritation is present, and when the disease threatens to attack 
the larynx. Dr. Laurie thinks that " when in addition to 
the formation of specks or patches of exudation of greater 
or less extent, with sore throat, enlargement of the tonsils 
or glands of the neck, disinclination for food, difficulty of 
breathing, cough and alteration of the voice ensue, the admin- 
istration of Iodine should be at once resorted to." Dr. Kidd 
says that the essential pathogenetic action of Iodine comes 
the nearest of all our remedies to the essential character- 
istics of diphtheria in its constitutional and local manifesta- 
tions. Dr. F. G. Snelling says that its internal use should 
be in frequent repetition, and accordingly he advises that 
ten drops of the first decimal dilution of Iodine be added to 
half a cup of pure cold water, a teaspoonful to be given 
every 20 or 30 minutes. " To produce a prompt and perfect 



DIPHTHERITIC CROUP. 27$ 

influence, Dr. Kidd thinks it best to administer it, ' similia 
similibus curaritur] in the mode of entrance of the disease 
itself — viz., by inhalation ; or the Iodine, in substance or in 
tincture, may be placed in an open vessel near the patient, 
as it is thus slowly evaporated, and mixes with the air in a 
highly divided and quickly acting form." — (Snelling.) Dr. 
McNeil, the best writer on the homoeopathic therapeutics of 
diphtheria that has yet appeared, says that,, it is only in 
rare cases that Iodine will ever be indicated " — and I entirely 
agree with him. 

Dr. Helmuth supplies us with the following valuable 
details as to the best mode of administration by inhalation : 
" When the disease is not arrested by these medicines 
(Caustic ammonia and Protiodide of mercury) — and there 
is the slightest appearance of cough — I order the inhalation 
of the vapor of Iodine, and that medicine in the second 
dilution, in water, every two hours. The inhalation is 
conducted as follows : a small teapot is filled with boiling 
water, and a teaspoonful of pure tincture of Iodine poured 
therein ; the patient takes the spout of the vessel in the 
mouth, and the head being covered with a towel, a few 
inspirations are made. This method is resorted to when 
there is no inhaling glass convenient, and it will be found to 
answer the purpose exceedingly well. The inhalation may 
be repeated three times during the day. There can be no 
doubt of the efficacy of this method of treatment — viz. : 
Iodine, internally and topically, by inhalation, in severe diph- 
theritis, even after the cough has commenced. I have 
witnessed its efficacy several times, and would have others 
test it in similar cases." 

Dr. Peters says that Bromine causes inflammation of a 
transudative character in the larynx and trachea, with 
commencing formation of false membranes ; violent inflam- 
mation of the fauces and oesophagus, and coating of them 
with plastic lymph ; intense inflammation of the larynx and 
trachea, with exudation of plastic lymph in such abundance 
as quite to block up the air passages. He adds that it is 



280 DIPHTHERITIC CROUP. 

rather more applicable to the inflammatory cases tending 
towards the larynx with sharp fever at the outset. Dr. J, 
P. Dake gives the following indications : " Soreness and 
smarting in the throat ; ptyalism ; hoarseness ; rough, dry 
cough ; sensation of contraction in the windpipe ; fluent 
coryza ; also nasal obstruction ; epistaxis ; earache ; alternate 
chills and heat ; violent inflammation of the mucous mem- 
brane of the fauces, oesophagus, also of the larynx and 
trachea ; these parts are covered with a coagulable lymph 
which obstructs almost entirely the air passage. A dingy, 
brownish, granular, firmly-adhering exudation over the 
mucous membranes of the oesophagus." Dr. Trinks recom- 
mends it in severe inflammation of the fauces and oesophagus 
covering them with plastic lymph, also in severe inflamma- 
tion of the larynx and trachea, with exudation of plastic 
lymph nearly closing these organs. Dr. Laurie recommends 
Bromine to be used in laryngeal diphtheria when Iodine 
has failed. Dr. McNeil advises Bromine " when the disease 
commences in the larynx and comes up into the fauces, and 
in some cases in which it runs down into the larynx and 
produces a croupy cough, with much rattling of mucus." 
Dr. W. C. Dake observes that " generally we have not had 
satisfactory results from its use," and Dr. Hughes says that 
" Bromine is the only rival of Kali bichromicum when diph- 
theria invades the larynx," yet his personal experience has 
not been favorable. Dr. Charles Neidhard, of Philadelphia, 
says, " I have been consulted in four or five cases of diph- 
theritic croup where Bromine was freely administered, in 
large and small doses, without any effect. They all died. 
In one or two of my own cases, it was also administered 
without benefit. It would seem that Bromine has not much 
effect in diphtheritic croup, nor in diphtheria generally." 
Personally, I have made little use of Bromine in this disease, 
partly because, as Dr. Bayes remarks, it is " an unmanageable 
medicine," and partly because I seldom saw grounds for its 
administration. I conclude that, though it is occasionally 
indicated in pseudo-membranous croup, it is not in homceo- 



DIPHTHERITIC CROUP. 28 1 

pathic rapport with diphtheria in any of its manifold phases, 
great care should be taken to preserve this remedy and the 
dilutions should be made each time it is used. "A gargle 
made with one drop of pure Bromine to six ounces of water 
has proved serviceable in diphtheria threatening to invade 
the larynx. It makes the false membrane brittle and brings 
it away, while it stimulates the subjacent mucous membrane." 
— (Baj/es.) 

According to Dr. Peters, Ammonium causticum causes 
reddening of the nasal mucous membrane which is coated 
with an albuminous layer ; reddening of the posterior surface 
of the epiglottis and of the entrance into the rima glottidis, 
which are covered with a false membrane ; great redness of 
the whole trachea and bronchi, which are coated here and 
there with membranous patches. He adds that it may be 
used in diphtheria when the prostration and exhaustion are 
very great, and the disease tends to extend down into the 
larynx, trachea and air passages. Dr. J. P. Dake states that 
he has used this remedy with gratifying results, by nasal 
inhalation, but has not found benefit from the internal 
administration of the drug. Dr. McNeil observes that as 
this remedy has been used but little, we need further 
clinical provings (cures?) to clearly establish its province in 
diphtheria. 

Dr. F. X. Spranger of Detroit reports the following cure 
in the American Homoeopathic Observer, Vol. I : "Among 
the many cases that I have successfully treated with this 
medicine, I shall mention but one. It was a case of croupous 
diphtheria ; a servant girl 20 years of age ; corpulent, 
plethoric constitution. When first called to see her she had 
a croupous cough, which threatened suffocation every 
moment. On examination, found the lower part of the 
pharynx covered with a white pseudo-membrane extending 
down as far as could be seen. Patient was in the greatest 
agony, frequently jumping out of bed and gasping for breath. 
I dropped 15 drops of Ammonium causticum into a tumbler- 
ful of water, one-half-teaspoonful to be given every hour. 



282 DIPHTHERTTTC CROUP. 

Left the patient soon afterwards, about 6 o'clock P. M. 
(The patient lived in the country.) While taking the first 
few doses she nearly strangled, deglutition being so difficult. 
Soon afterwards she began to get easier. Next morning I 
found the patient sitting up in bed, breathing freely. Had 
taken some broth ; deglutition was very easy ; the pseudo- 
membrane had entirely disappeared, and the patient was 
discharged cured the next day afterwards." Commenting 
on this, Dr. Oehme remarks that " though there is but one 
cure on record, yet we are forced to consider Ammon. caust. 
a great remedy in diphtheritis." 

Excellent observers of the dominant school bear unwitting 
testimony to the homceopathicity of this remedy to the 
diphtheritic process. Thus Trendelenburg found that it was 
capable of causing the formation of false membranes in the 
trachea; and Dr. H. C. Wood confirms the observation. 
Delafond called " croup " into existence by means of 
Ammonia, and Oertel constantly insists on there being " no 
actual difference between croup as it ordinarily occurs, and 
that excited in the windpipe of a rabbit by means of 
Ammonia. The color and texture, the physical, chemical, 
and histological characteristics are identical/' 

Dr. Hughes advises Apis mellifica in the ' croupal ' form 
of diphtheria " when a lower type of inflammation (as shown 
by a mere purple color of the parts) and much greater 
oedema are the first signs of the supervention of the croupous 
upon the catarrhal form ofj*diphtheria, or of its primary 
onset." Dr. Oehme, whose work on the therapeutics of 
diphtheria is simply invaluable, remarks : " Because one 
physician has found Apis of no benefit in diphtheritis of the 
larynx, it does not follow that it will be thus in all cases, as 
we cannot expect one drug to be the only remedy for this 
disease." And he adds: "If we take into account the 
following symptoms : " Voice grew hoarse ; breathing and 
swallowing very difficult ; difficulty of swallowing not caused 
by the swelling of the throat, but by the irritation of the 
epiglottis ; sensation as of a rapid swelling of the lining 



DIPHTHERITIC CROUP. 283 

membrane of the air-passages ; rough voice ; speaking painful ; 
hoarse cough ; intense sensation of sufTo:ation, could bear 
nothing about the throat ; hurried difficult respiration ; 
labored inspiration as in croup, etc.;" we see no reason why 
it should be neglected in these cases." In confirmation 
of these indications, I report the following case in the 
American Observer, Vol. XV: " On November 20th, 1877, 
I was called to W. S., a boy aged nine years. He had 
flying chills, followed by great heat with debility ; pulse 108 ; 
temperature in the axilla, I02|°. The throat was very red 
with difficult deglutition and severe pains, felt even when 
not swallowing. I prescribed Apis mel., 5th dec. trit., one 
grain in eight teaspoonfuls of water, a teaspoonful every 
hour. At the same time I ordered the Grauvogel gargle, 
composed of equal quantities of spirits of wine and water, 
every two hours during the day, together with a diet exclu- 
sively of milk. For two days the situation remained almost 
unchanged, but on the morning of November 23d, a thick, 
yellowish, diphtheritic exudation covered the uvula, tonsils 
and pharynx, while the tongue had a thick, yellowish coating 
with inflamed papillae and a high degree of fetor. The 
diphtheritic membrane was of the consistence of clotted 
cream, of a yellowish color, closely adherent to the subjacent 
mucous membrane, and of a fetid smell. The fever increased, 
and the morning temperature averaged 102^° and the 
evening \Q>i\° . No solid food could be taken, and small 
quantities of milk formed the sole nourishment. The 
Granvogel gargle was continued, though it caused intense 
pain each time it was used. The weakness and prostration 
increased to an alarming extent, and the characteristic bluish 
tint of the face was distinclty marked. The nostrils now 
became affected, and poured out a thin, fetid sanies. On 
November 28th the membrane extended lower down the 
pharynx, and on the following day the hoarse and croaking 
voice announced that the pharynx was at last involved, and 
this was confirmed by the stethoscope. Apis was now given 
in grain doses of the 5th dec. trit., dry on the tongue, every 



284 DIPHTHERITIC CROUP. 

two hours. On November 30th the voice was entirely 
suppressed, with a hoarse and difficult cough, accompanied 
by the expectoration of small quantities of membrane. On 
December 1st the uvula began to shed its membrane, and 
during the five following days an astonishing amount of 
membrane was partly expectorated, partly vomited. Not- 
withstanding the very serious state of the larynx, no change 
was made in the remedy, except that the Grauvogel gargle 
was discontinued. On December 6th the tonsils and pharynx 
were almost clear of membrane, the voice returned, the 
laryngeal cough became softer, and the patient — very wan 
and prostrate — entered on convalescence. Throughout the 
entire progress of the disease, the patient presented Guern- 
sey's key-note symptom, u Puffiness about the eyes." Dismissed 
on December 8th, no remedy but Apis having been used. 
Since this case was reported, I have attended three others, 
strikingly similar to it, in which the same results were 
obtained from Apis. 

Oehme gives the following excellent indications for 
Lachesis : " The subjective symptom much severer tlian the 
objective ; violent pain in the throat ; extremely painful and 
difficult swallowing ; sensation of a foreign body in the 
throat, with stinging extending into the ear ; urgency to 
swallow, and desire to hawk up something, with choking 
spells ; dislike to have the throat touched ; pale redness of 
the fauces ; exudate begins or is worse on the left side ; voice 
weak and hoarse ; aphonia ; cough causes pain ; fcetor oris ; 
fetid discharge from mouth and nose ; violent prostration, 
even before the exudation ; lassitude ; weakness ; pulse weak, 
small; perspiration cold, clammy; somnolency; delirium; 
symptoms worse after sleepy 

Dr. William Morgan says of this remedy : " This remark- 
able production of the animal kingdom may always be 
trusted as an auxiliary in removing that distressing and 
painful sensation of strangulation and suffocation, as if a 
cord were tied tightly round the throat, which marks certain 
forms of scarlet fever, the phlegmonous sore throat and 



. DIPHTHERITIC CROUP. 285 

diphtheria ; indeed, I have never found Lachesis fail in this 
important symptom ;" but as Dr. McNeil well remarks, 
" Lachesis is one of our most important remedies in both 
the laryngeal and septic forms," adding that " the indica- 
tions are so clear that mistakes are inexcusable." 

Dr. Ludlam, of Chicago, was the first to point out, on the 
authority of M. Laboulbene, that the constitutional action 
of Tartar emetic will produce a pseudo-membrane upon the 
buccal, the laryngeal and the tracheal mucous surfaces. 
"The indications which, in my own experience, more 
frequently require this remedy in diphtheria, are sudden 
swelling of the cervical glands and tonsils, occurring in 
scrofulous children, who are predisposed to catarrhal or 
asthmatic affections ; occlusion of the larynx or lower 
respiratory channels by excess of mucus, or of a feebly 
organized plasma, with cough, dysphagia, difficulty of 
breathing, gasping (which compels the patient to sit upright 
or to seek the open air) ; inclination to retching and 
vomiting, obstinate vomiting of a tenacious mucus without 
any considerable thirst ; small circular patches, like small- 
pox pustules, in and upon the mouth and tongue ; and also 
for evidences, of closure of the pulmonary air vesicles by 
solidification of effused serum (hepatization). It will some- 
times serve a good purpose by promoting diaphoresis, and in 
exceptional cases will drive out the eruption, to the great 
relief of internal mucous surfaces. I reccommend you not 
to overlook the claims of this remedy in certain forms and 
varieties of the diphtheritic lesion. In particular, it seems 
applicable to many cases of diphtheria in which the abnormal 
throat and chest symptoms derive their chief characteristics 
from a prevalent influenza, or from an inherent predisposi- 
tion on the part of the patient to catarrhal disorders of the 
respiratory mucous membrane." — (Ludlam). The writer has 
used Tartar emetic to a considerable extent, but thinks that 
it is more appropriate for pseudo-diphtheria than in the 
genuine disease. As to the dose, a grain of the 3d or 4th 
decimal trituration may be dissolved in half a cup of water 



286 DIPHTHERITIC CROUP. 

and a teaspoonful given every one or two hours, or a small 
powder of the 5th or 6th trituration may be given dry on 
the tongue every two hours. 

If the diphtheritic laryngitis should be a primary disease, 
good results may be expected from Aconite, provided it is 
given promptly and in material doses, certainly not higher 
than the 2d dec. dilution, but if it does not check the 
disease at once, some other remedy should be substituted 
for it. 

Sir George Duncan Gibb recommends Sanguinaria " as an 
emetic in the croupal form of diphtheria." My own experi- 
ence is that when the membrane is diffluent this remedy is 
effective, but not when the membrane is tough and closely 
adherent to the mucous membrane. 

Dr. W. C. Dake, who, has had excellent results in this 
disease, seems to consider that Spongia rivals Kali bichro- 
micum. He advises " Spongia for paleness of the face and 
anxious features ; stitches in the throat, great dryness of the 
larynx, with short, barking cough ; difficult breathing, as 
from constriction of the larynx and trachea ; pain in larynx 
when pressing upon it ; hoarseness ; dry cough, worse in the 
evening and toward morning from a tickling in the wind- 
pipe." Dr. Dake gives Spongia in the 1st decimal dilution, 
a dose every hour. 

Aphorisms. 

1. Diphtheritic croup is the development upon the larynx 
and trachea of the characteristic membrane of diphtheria, 
and, as a general rule, the disease originates by extension 
from the pharynx, it being a very rare thing to find it origi- 
nate in the larynx. 

2. In some epidemics, laryngeal diphtheria is so common 
as to give the characteristic features and name to the disease, 
while in other epidemics it is very rare. 

3. It is more common in low, swampy lands, and on the 
margin of bodies of water, than on high and rolling land, 



DIPHTHERITIC CROUP. 287 

4. The proportion of cases of laryngeal diphtheria, as 
compared with the whole number of cases of diphtheria, 
varies from 15 to 67 per cent., and the mortality in cases of 
diphtheria in which the larynx is attacked, varies from 40 to 
95 per cent. 

5. Many of the croup epidemics of the eighteenth century, 
in England, Scotland and omthe North American Continent, 
were epidemics of what would now be called diphtheritic 
croup. 

6. When death takes place in diphtheria within a week, it 
is usually by extension of the disease to the larynx ; when 
death takes place later, it is almost always the result of 
asthenia. 

7. The characteristic membrane is of various textures, 
sometimes as soft as thick cream, sometimes like moist kid- 
leather. 

8. The membrane may extend from the epiglottis to the 
minute ramifications of the bronchial tubes, and as it 
descends it becomes less and less consistent. 

9. The prognosis is very unfavorable, even under enlight- 
ened homoeopathic treatment, and the danger largely arises 
from the fact that the patient is suffering from a serious 
blood poisoning in addition to the local disease, and also 
that when the laryngeal complication appears the patient is 
already exhausted by the primary disease. 

10. The younger the child the greater the danger of 
diphtheritic croup coming on in the course of diphtheria, 
and the younger the child the greater the danger when it 
does make its appearance. 

11. As to therapeutics, Kali bichromicum heads the 
column, closely followed by Apis mellifica, Lachesis and 
Ammonium causticum. Of lebs importance, but still deserv- 
ing of careful study, are Spongia, Iodine, Aconite, Sanguin- 
aria, Bromine and Tartar emetic. 

12. While tracheotomy is often the last reserve — and a 



288 SCARLATINAL CROUP. 

successful one too, if not too long delayed — in true croup, it 
is seldom admissible in diphtheritic croup. 

13. The physician may sometimes be tempted to use an 
emetic for the purpose of removing the membrane from the 
larynx, but the relief is, at best, only temporary, and the 
irritation of the emetic action often intensifies the disease 
and hastens the fatal issue. 



CHAPTER X. 



Scarlatinal Croup. 



Scarlatinal croup is a phase of disease to which exceed- 
ingly little reference is made in the medical writings of any 
school, and yet, though it is fortunately infrequent, it 
requires skill and promptitude more than any other compli- 
cation of scarlatina. Objection may be made to any separate 
chapter on this subject, as the malady forms one phase of a 
general disease, and hence should be described with that 
disease. However, on account of the dangerous nature of 
the complaint, and also in view of the fact that no essay on 
the subject is contained in the literature of our school, I 
have thought it best to present the following chapter. 

Scarlatinal croup, then, is a secondary inflammation of the 
larynx, occurring almost exclusively in the most malignant 
forms of scarlatina when the whole mass of fluids has been 
vitiated. It may originate by extension of the inflammatory 
irritation from the pharynx, though it sometimes appears 
when the pharynx is but little affected. 

Scarlatinal croup is not a common phase of disease, for in 
the words of Professor Trousseau, " scarlatina has no liking 



SCARLATINAL CROUP. 289 

for the larynx." It may appear in patients of any age, but 
it seems to me to be most frequent between the ages of four 
and eight. I have never noted it in infants, and all my 
patients, except two, were under ten years of age. Both 
sexes seem to be alike liable to the disease. 

In many instances, scarlatinal croup originates by extension 
of the well-known sore throat of scarlatina, but in most of 
the cases I have observed, exposure to cold was the exciting 
cause. The illustrious Sydenham — doubtless encouraged by 
the success of his cool regimen in small-pox — thought that 
scarlatina patients ought to get up every day, even when the 
eruption was at its height. But scarlatina patients are much 
more susceptible to cold than small-pox patients ; in fact, 
above all the eruptive fevers scarlatina needs to be guarded 
against cold. All my fatat cases originated in exposure to 
cold. One wilful nurse stripped a little patient to the skin 
at the height of scarlatina, and carried it about in a fireless 
kitchen for the purpose of " cooling the fever." Scarlatinal 
croup came on, and the case was hopeless when next seen. 
Another woman kept her little one, sick of scarlatina, in a 
well-warmed room during the day, but every night removed 
it to her own fireless bedroom situated at the extremity of a 
long, rambling farm-house, and this, too, during the month 
of February, 1868 — the coldest part of the most severe 
Winter I ever saw in Canada. Here, too, the larynx was 
attacked with fatal result. In January, 1870, among other 
scarlatina patients I had one who made a fair recovery, 
though the type of disease was malignant. After I dismissed 
the case, the mother kept the cradle exposed to the cold air 
blowing in through an imperfectly-closed window, and fatal 
scarlatinal croup was the result. 

Croup may come on during the early stages of scarlatina, 
or it may be one of sequelae. It usually comes on insidiously 
and, amidst the anxiety of a serious disease, it may be 
unnoticed for a time. There is at first a very slight 
hoarseness, with muffled cough and a mingled gurgling 
and trilling sound in the larynx ; after the cough the 



29O SCARLATINAL CROUP. 

gurgling disappears for a time. These symptoms are 
frequently preceded by a slight chill, followed by heat of 
skin and accelerated pulse, but this may easily pass without 
remark. At first there is no dyspnoea, but soon marked 
difficulty of breathing comes on, and the dyspnoea indicates 
the degree of danger present, which is usually in precise 
proportion to this symptom. The patient involuntarily rises 
in bed and stretches out the head, while the eyes have an 
anxious and haggard expression. The cheeks are flushed 
and the eyes suffused. At this stage the tissues of the neck 
become swollen and infiltrated, and this, of course, increases 
the dyspnoea and hoarseness. There are no intermissions in 
this variety of croup; there is, however, a very slight remission 
in the morning, and usually a very severe exacerbation 
during the hours immediately before and after midnight. 
There is, in a majority of cases, a steady, onward march of 
the disease, the dyspnoea increases, the respiration becomes 
more stertorous, the cough, after becoming harsher, is finally 
suppressed, the strength fails, wild terrors and the ever- 
present feeling of suffocation prevent sleep, and finally the 
patient dies, comatose or convulsed. But, on the other 
hand, under the influence of a well chosen remedy, the 
dyspnoea may decrease, the cough may become less frequent 
and less hoarse, quantities of membrane may be vomited or 
swallowed, and the sleep of the patient then announces that 
the pressing danger has passed away. In another group of 
cases croup comes on suddenly and almost without warning. 
At one visit you leave your scarlatina patient doing well, 
and, when you next see him, the case is hopeless or almost 
hopeless. 

The progress of this disease is very rapid, even more so 
than pseudo-membranous croup. Most of the fatal cases I 
have seen lived only from two to three days. 

The false membrane of scarlatinal croup is thinner, softer 
and less adherent than the membrane of pseudo-membranous 
croup ; at the same time, it is less uniformly spread over the 
affected part. It is grayish or of a yellow color, and is 



SCARLATINAL CROUP. 29 1 

frequently associated with small quantities of pus, or it may 
be granular in texture and friable in consistence. But little 
fibrin enters into its composition and it rapidly decomposes. 
The subjacent mucous membrane is softened and of a dark 
purplish hue, while the sub-mucous areolar tissue is infiltrated; 
in fact, all the pathological appearances point to the locali- 
zation of a degenerated blood disease. Professor Wood 
remarks that the membrane seldom extends, unless in 
small quantities, below the larynx. 

In the great majority of cases the diagnosis is plain, for 
the history of the case must be investigated as well as the 
present state of the patient. The only cases in which there 
is reasonable ground for doubt are those which Trousseau 
denominates defaced scarlatina (scarlatine fraste), in which 
some of the most important symptoms of the malady are 
suppressed or non-existent. When, for example, there is no 
appearance of the characteristic eruption, but instead you 
have severe sore throat, with deposition of false membrane, 
it would be difficult to decide whether the disease was 
scarlatina or diphtheria, for a fetid smell exhales from the 
mouth and nostrils, the pulse is small and fluttering, the skin is 
pale and the temperature of the body is notably low. In 
such cases one of the best diagnostics would be the period 
at which albuminuria appeared, for, as is well known, in 
diphtheria it appears early in the disease, while in scarlatina 
it does not make its appearance till the case is far advanced. 
But in about one-fifth of the whole number of diphtheritic 
cases there is no albuminuria, and then the physician must 
look for other diagnostic points. There are two sources of 
fallacy in scarlatinal croup, to which I would direct special 
attention. The first of these will be found in the phenomena 
presented by a certain number of cases of scarlatina in 
which a quantity of matter in the posterior nares and upper 
part of the pharynx forms a mucous rhoncus which closely 
simulates croup. But here auscultation clears up the 
difficulty at once by showing that the larynx is not involved. 
In another set of cases the tumefaction of the neck is so 



292 SCARLATINAL CROUP. 

great that it causes stertorous respiration, which bears a 
certain resemblance to croup. Here, too, auscultation is of 
some value, but a better diagnostic is the absence of the 
hoarse cough. 

I look upon scarlatinal croup as being one of the most 
fatal of all the varieties of croup. It is more dangerous 
when it comes on at an advanced period of the course of 
scarlatina — say the tenth or twelfth day — than when it 
attacks at an early period. It is very dangerous when it 
arises by extension from the pharynx, but it is still more 
dangerous when it appears as an intercurrent inflammation, 
the result of exposure to cold. Tumefaction of the neck, if 
of great extent, is an unfavorable sign, and when coma or 
delirium appear there is little room for hope. Much, very 
much, depends upon prompt recognition of the disease and 
upon equally prompt therapeutics. 

But one of the weak points about our knowledge of 
scarlatinal croup is that we have no well-defined treatment 
such as we possess in so many affections, and I regret that I 
can give but a few fragmentary hints derived entirely from 
personal experience. Here I cannot refrain from again 
pointing out the necessity of opposing the very beginnings of 
disease. " Obsta principiis." 

When recognized at an early period, Aconite is indicated 
in a majority of cases, but it should be given in the form 
tincture, as dilutions are merely a waste of invaluable time. 
I have great confidence in Sanguinaria and the confidence 
is derived from the fact that since I have used this remedy 
I have been much more successful than formerly. 

A homely proverb says that "an ounce of prevention is 
worth a pound of cure," and I. am strougly of the opinion 
that inunctions of olive oil are preventive of scarlatinal 
croup as well as of many of the complications and sequelae 
of scarlatina. I use them in every case of scarlatina as 
follows : I direct one arm of the patient to be bathed 
lightly with tepid water, and then quickly dried, and, when 
thoroughly dry a small quantity of pure olive oil is rubbed 



SCARLATINAL CROUP. 293 

over the limb. Then the other arm is treated in the same 
manner, and so on, till the entire person has been bathed 
and anointed. As a result the temperature is lowered, the 
irritation of the skin is allayed, and the liability to take cold 
is almost wholly removed. 

Aphorisms. 

1. Scarlatinal croup, fortunately not a common disease, 
appears in children of any age, and both sexes seem to be 
alike liable to it. 

2. The disease may originate by extension from the 
pharynx, but it is most commonly caused by exposure to 
cold. 

3. Scarlatinal croup is one of the most rapidly fatal of all 
the forms of croup, and it is more dangerous when it appears 
late in the course of scarlatina than when it comes on at an 
early period. 

4. The leading remedies are Aconite, Sanguinaria and 
Kali bichromicum, and inunction with olive oil is the best 
prophylactic. 



CHAPTER XL 



Tracheitis. 



Is there such a disease as tracheitis? To read one series 
of medical authors, one would quite believe that there was 
such a disease, distinctly marked and well known, and as 
thoroughly understood as any malady in the nosological 
tables. To read another set of writers — quite as eminent 
and quite as well informed as the other— one would conclude 
from their brief remarks, and still more from the silence of 
some of them, that while all other parts of the human 
organism may be the victim of what the lamented Constan- 
tine Hering used to call " an if is-" the trachea was the one 
happy spot which never knows what inflammation means. 
By one group of writers tracheitis is considered to be synon- 
omous with croup. Sir Thomas Watson — the Macaulay of 
British Medicine — speaks of "another of Dr. Cullen's species 
of cynanche — viz.: cynanche trachealis — tracheitis — croup;" 
and Hasse — perhaps the most eminent of the Swiss patholo- 
gists — considers tracheitis and croup to be interchangeable 
terms. When such curious errors are made by the great 
lights of the school of medicine which has most zealously 
cultivated pathology and pathological anatomy, one does 
not wonder to see the author of the Hydropathic Encyclo- 
paedia follow in their wake. 

George B. Wood, M. D., formerly Professor of Theory and 
Practice of Medicine in the University of Pennsylvania — 
certainly the greatest writer on disease that this continent 
has yet produced — offers the following remarks: "In a 
pathological account of the several portions of the air 
passages, it might be thought that the trachea would receive 



TRACHEITIS. 295 

a separate consideration ; but it is very seldom exclusively 
affected, offers no symptoms when inflamed which are not 
observed in other localities, and requires absolutely nothing 
peculiar in its treatment. The nomenclature which gives 
the title of tracheitis to croup is founded on a false assump- 
tion in relation to the special seat of that complaint. It is 
true that the trachea is generally affected in croup ; but it is 
almost never exclusively affected ; nor are the peculiar 
features of the disease essentially connected with that part 
of the respiratory passages. The symptoms and treatment 
of tracheitis are almost always merged in those of laryngitis 
and bronchitis." The fact that the trachea is very seldom 
exclusively affected, is not a good reason for passing over 
the disease altogether, as the same remark might be made 
respecting some other parts of the organism ; and it is 
difficult to understand what is meant by the remark that it 
" offers no symptoms when inflamed which are not observed 
in other localities," seeing that tracheitis is quite different 
from the inflammations of kindred regions, and that the 
same remark might be made regarding almost any local 
inflammation — especially the inflammations of the enceph- 
alon. The remark that the disease " requires absolutely 
nothing peculiar in its treatment/' is quite in place with 
therapeutics who are groping in the twilight of the so-called 
" physiological medicine," but it is repudiated by those who 
heal the sick in accordance with a great law of nature. 

Tracheitis, then, may be defined to be an inflammation of 
the mucous membrane of the windpipe, usually arising from 
exposure to cold, and characterized by a croup-like cough 
with profuse secretion of mucus. This inflammation may 
be either primary or secondary ; in the latter class it reaches 
the trachea by extension from the larynx. Although the 
inflammation may extend downwards from the larynx to the 
trachea, it is rare to find it extending upwards from the 
trachea to the larynx, and a similar remark may be made as 
to the relation between tracheitis and bronchitis. Indeed, 
it seems to be a general law that inflammations of the respir- 
atory organs extend downwards. 



- 296 TRACHEITIS. 

Tracheitis is usually a catarrhal inflammation, though it is 
sometimes sthenic. Very seldom has the writer seen it of a 
pseudo-membranous nature, though it is well to bear in 
mind Rindfleisch's caution: "the development of a false 
membrane is connected in the closest manner with the 
catarrhal state, and constitutes the anatomical acme of the 
morbid process." It is, perhaps, never diphtheritic, though 
diphtheria may extend from the larynx to the trachea. 
This disease has no separate history, for, following Cullen's 
vicious nosology, it has almost invariably been confounded 
with croup, from which it differs in many important partic- 
ulars. Almost all writers who have recognized the existence 
of tracheitis have remarked its infrequency, but a more 
careful examination, and especially the more frequent use of 
the stethoscope, would have proved that it is quite frequently 
met with. Boys are more subject to it than girls, and it is 
more frequent in fall and spring than at other seasons of the 
year. 

Exposure to draughts of cold air is the most usual cause 
of tracheitis, but in children wet feet will usually be found 
to be the starting point of the disease. Children who have 
been confined to the house during the winter season are 
very apt to be attacked with laryngeal and tracheal inflam- 
mations when they first go out in spring, and nearly all the 
writer's cases occurred in March and April. Previous attacks 
form an undoubted predisposing cause of the disease, and 
the susceptibility is increased with each attack. 

Tracheitis is usually preceded by premonitory symptoms 
resembling those of catarrh. The patient has more or less 
chilliness — not the distinctly marked chill of a sthenic 
inflammation, but a creeping, disagreeable feeling of 
chilliness, intermingled with heat — and this chilliness is 
followed in increased heat of the surface, with marked 
lassitude and loss of appetite. Felix von Niemeyer points 
out that this chilliness is rarely confined to a single rigor, 
thus forming an important point of distinction between the 
onset of a catarrhal and of an inflammatory fever. Shiver- 



TRACHEITIS. 297 

ings recur with every little alteration of temperature, or on 
such slight exposure as changing the linen. A dull frontal 
headache is present, with throbbing of the temporal arteries, 
bruised pain in the' limbs, and pain in the joints, increased 
by pressure or motion. 

Sometimes there is only a slight irritation in the trachea, or 
a kind of tickling which provokes a short, hacking cough, but 
usually the cough is violent and paroxysmal. This cough is 
of three, tolerably distinct varieties, according as the inflam- 
mation is confined to the windpipe, or, in addition, touches 
the larynx or the bronchi. When the inflammation is 
confined to the trachea, the cough is at first dry and 
spasmodic and of frequent recurrence, later there is an 
expectoration of thick, ropy mucus ; when the larynx is 
implicated, the cough is hoarse, metallic and convulsive, 
while the breathing is loud and wheezing ; when the disease 
invades the bronchi, the cough is dry at the commencement, 
but becomes looser in two or three days, with sputa of frothy 
mucus mixed with pus and sometimes streaked with blood. 
Prosser James remarks that " the voice will be unaffected so 
long as the larynx is not also involved ; " but I have noted 
that even when the larynx is not affected the voice has a 
ringing and metallic sound which is quite distinct from the 
hoarse clangor of true croup. There is no real dyspncea in 
tracheitis, owing to the large calibre of the affected organ as 
compared with that of the larynx or bronchi. The expec- 
toration in simple tracheitis is more copious than in 
laryngitis, but much less abundant than when the bronchi 
are involved in the inflammatory action. Prosser James 
says that occasionally the expectoration appears in rings ; 
I have never observed this phenomenon. As might be 
expected from the anatomical relations of the trachea and 
oesophagus, there is considerable dysphagia accompanied by 
a feeling of constriction ; sometimes this is so considerable 
that the ingesta returns by the nostrils and mouth. The 
cause of this is obvious, for, as the lower extremity of the 
trachea is necessarily fixed, it follows that the upper extrem- 



298 TRACHEITIS. 

ity moves upwards with the larynx in swallowing, and, 
therefore, if the tracheal mucous membrane is inflamed, pain 
must be felt during deglutition. Morell Mackenzie denies 
the occurrence of dysphagia in the course of tracheitis, on 
the ground that though he has watched for the symptom 
he has never yet met with it, but a very slight acquaintance 
with the rules of evidence shows the futility of such an 
argument. In severe cases there is considerable swelling of 
the neck, but this is rare. The characteristic .pain of 
tracheitis is a burning, stinging pain, aggravated by pressure 
and motion, and felt much lower down than the pain of 
laryngitis or croup. 

Like croup, tracheitis usually developes itself during the 
night. The patient has usually been suffering from what 
was assumed to be a slight cold, and has retired to bed, 
apparently in good health, but in the night he awakes with 
the spasmodic cough and the loud and ringing voice, while 
at the same time the skin is hot and the face flushed. 
During the day the malady intermits, but on the approach 
of evening the paroxysm reappears in an aggravated form 
and with increased fever. The cough becomes more 
frequent and more annoying, and the thick, ropy mucus can 
be distinctly heard rattling in the windpipe. Should the 
disease be controlled by proper treatment, the cough 
diminishes and the characteristic burning and stinging pain 
disappears ; the voice resumes its natural tones, and the 
fever subsides, leaving behind it languor and malaise. If 
the patient is old enough, free expectoration takes place, 
but in a majority of cases the secretions are brought up to 
the pharynx and then swallowed. Relapses are quite 
frequent, and the patient is ever after subject to the disease. 
In cases which terminate unfavorably, the bronchial tubes 
become involved, the cough increases in frequency, the 
expectoration becomes purulent and profuse, the appetite 
fails, and the body emaciates, till the child sinks into its 
grave with a group of symptoms closely resembling those of 
phthisis pulmonalis. 



TRACHEITIS. 299 

Tracheitis of a sthenic nature lasts from five to seven days, 
and is more easily cured and is less likely to become chronic 
than if it were catarrhal in its nature. It is also less likely 
to invade the bronchi. Pseudo-membranous and diphtheritic 
tracheitis are rarely found, save as parts of one general 
disease from which the patient has but little chance of 
recovery. Catarrhal tracheitis is the most common variety, 
and so far as my experience goes, is comparatively 
easy of cure, but it often recurs and is apt to become 
chronic. In a great majority of cases it extends to the 
bronchial tubes, and this bronchitis is apt to become 
chronic. Chronic tracheitis may last for many months, and, 
as in one case which I observed, may linger for a year, 
getting alternately better and worse, till at last recovery 
takes place. Such cases may be complicated with chronic 
bronchitis, when, as has been remarked, the case will strongly 
resemble consumption. 

Usually the thermometer shows an elevation of tempera- 
ture, say from one to two degrees above health, at the 
commencement of the illness, while further on the temperature 
may be normal or nearly so. I have attended a number of 
cases in which the temperature remained normal throughout, 
and again, as von Niemeyer points out, during the intervals 
of the shiverings the patient may experience a sensation of 
burning heat, without any indication from the thermometer 
of an actual increase of temperature. 

The laryngoscope can very rarely be used with young 
children, but the stethoscope gives equally valuable results. 
At the commencement of the disease sibilant rales are heard 
all over the tracheal region, with increased vocal resonance. 
When secretion takes place, large mucous rales replace the 
sibilant ones, and when the tracheal mucous membrane is 
swollen at some particular point a well-marked, sonorous 
rhoncus is heard. 

Post mortem examinations, as well as examinations with 
the laryngoscope during life, show that in this disease the 
lining membrane of the trachea is of an intense scarlet 



300 TRACHEITIS. 

redness, deepening into purple in very severe cases. The 
entire membrane is made up of a congeries of minute florid 
blood-vessels, so closely packed together as to give the 
characteristic scarlet hue. At the same time, the follicles 
are enlarged and very prominent, appearing like minute red 
points projecting from the inflamed surface, which has a 
kind of glazed appearance. These follicles form the source 
of the thick and ropy mucus which is coughed up. Ulcers 
are not common, and softening is rarely or never present, 
either in this disease or in laryngitis. Prosser James points 
out that when infiltration takes place it is more apt to be 
fibrinous than serous. In chronic tracheitis the redness is 
less than in the acute form, and the vessels are often 
varicose ; the mucous membrane is often hypertrophied, 
indurated and ulcerated. 

The diagnosis is comparatively easy. There is, of course, 
nothing characteristic in the fever which precedes the attack, 
for that is merely the fever common to all local inflammations. 
More characteristic are the burning, stinging pain, with its 
peculiar anatomical seat, the clear and ringing cough, with 
the gurgling of mucus in the windpipe, and in severe cases, 
the dysphagia, with constriction and swelling. 

The prognosis in catarrhal or sthenic tracheitis is almost 
uniformly favorable — differing widely in this respect from 
laryngitis or ' brochitis. The principal danger is the 
disposition to become chronic and to extend to the bronchial 
tubes. Still, one can easily conceive that there would be 
danger if a young infant of feeble vitality should be attacked 
with catarrhal tracheitis with a very copious secretion of 
mucus. 

The room in which- the patient sleeps should be nearly of 
the same temperature as that which he occupies during the 
day, and while draughts should be carefully avoided, 
ventilation should be as carefully maintained. Warm 
moisture should be added to the atmosphere of the room in 
severe cases, and great care should be taken when the 
patient first goes into the open air after recovery. 



TRACHEITIS. 30 1 

Aconite must ever be the first remedy thought of if the 
physician is called at or near the commencement of the 
illness. It is adapted to the etiology of the disease, for 
exposure to wet and cold is by far the most influential 
factor in its causation. If, however, the physician is not 
called during the first forty-eight hours, Aconite is of little 
or no avail and another remedy must be selected according 
to the symptoms present. I have generally used Aconite 
from the mother-tincture to the 3d decimal trituration, and 
see no necessity for going higher in the scale. 

In the catarrhal form no remedy equals Sanguinaria, 
which, moreover, is able to prevent extension to the bron- 
chial tubes, and also the recurrence of the disease. I am 
thoroughly convinced that when patients subject to croup 
or tracheitis are treated with Sanguinaria, they lose the 
predisposition to these diseases. Usually after a few prelim- 
inary doses of the inevitable Aconite, I give Sanguinaria 
with unvarying success, though exceptional cases occur 
which demand other remedies. 

Tartar emetic is indicated when the cough is very frequent 
with audible rattling of mucus in the windpipe and bronchi 
— the mucus is tough, white and copious. The larynx is 
little affected, but inclination to vomit is often present. 
Threatening paralysis of the lungs is best met by this 
remedy. Tartar emetic acts best in repeated doses of the 
3d or 4th decimal trituration. 

Mercurius solubulis is an excellent, remedy in catarrhal 
tracheitis ; dry, distressing cough, usually recurring at night 
and racking the entire frame. The patient is sensitive to 
cold, chills alternate with paroxyms of burning heat, and the 
tracheitis is merely the most prominent part of a general 
catarrhal fever. I have generally given this remedy in 
powders of the 6th decimal trituration, dry on the tongue. 

Spongia is indicated when the cough is hoarse, ringing 
and hollow, with labored and wheezing breathing. The 
cough is distinctly paroxysmal, and is usually without expec- 
toration. Spongia acts in all dilutions ; I usually give the 
6th decimal trituration. 



302 TRACHEITIS. 

i 

Hepar is very like Spongia, differing from it in the large 
quantity of mucus present. The cough is hoarse and barking, 
and a suffocative feeling is almost constantly present. 
Hepar acts well in all dilutions; I prefer the 12th decimal 
trituration. 

Sulphur is frequently indicated towards the close of the 
disease when a dry cough remains with feeling of constriction 
in the chest, worse after eating or during deep inspiration. 
The 30th is the most suitable preparation. 

Aphorisms. 

1. Tracheitis exists as a separate disease, though, as it 
often co-exists with laryngitis and bronchitis, its existence 
has been questioned. 

2. The leading symptoms are a burning, stinging pain in 
the windpipe, with dysphagia and local swelling. These 
symptoms are preceded by fever and accompanied by dry, 
spasmodic cough and ringing voice. 

3. The prognosis is almost uniformly favorable, but the 
disposition to become chronic and to extend to the bronchi 
should be carefully guarded against. 

4. The homoeopathic remedies are Aconite, Sanguinaria, 
Tartar emetic, Mercurius solubulis, Spongia, Hepar and 
Sulphur. Sanguinaria removes the predisposition to the 
disease. 



INDEX 



Aconite, in acute coryza, 
in purulent coryza, 
in spasm of the glottis, 
in acute catarrhal laryngitis, 
in acute cedametous laryngitis, 
in spasmodic croup, 
in pseudo-membranous croup, 
in diphtheritic croup, 
Ailanthus, in chronic coryza, 
Allium cepa, in acute coryza, 
Alumina, in chronic coryza, 
in scarlatinal croup, 
in tracheitis, 
Ammonium carbonicum, in acute coryza, 
Ammonium causticum, in diphtheritic croup, 
Antimonium crudum, in chronic coryza, 
Apis mellifica, in purulent coryza, 

in acute cedematous laryngitis, 
in diphtheritic croup, 
Argentum nitricum, in purulent coryza, 
in chronic coyr/a, 
in acute catarrhal laryngitis, 
Asafcetida, in chronic coryza, 
Arsenicum album, in acute coryza, 

in spasm of the glottis, . 
in acute catarrhal laryngitis, 
in acute cedematous laryngitis, 
Arsenicum iodatum, in chronic coryza, 
Arum triphyllum, in acute coryza, 
Aurum metallicum, in chronic coryza, 
Baryta carbonica, in chronic coryza, 
Belladonna, in acute coryza, 
in purulent coryza, 
in spasm of the glottis, 
in acute catarrhal laryngitis, . 
Berberis, in chronic coryza, 
Bouchut, on the use of canulse in acute coryza, 
Bromine, in spasm of the glottis, . 

in pseudo-membranous croup, . 
in diphtheritic croup, 



PAGE 

29, 37 

49 

89 

127 

147 

164 

218 

286 

63 

34 

58 

292 

301 

36 

281 

62 

49 

143 

282 

47 
57 
131 
63 
32 

91 

130 

148 

62 

36 

57 

59 

33 

49 

92 

129 

• 63 

37 
108 
225 
279 



304 



INDEX 



Bryonia, in acate cor za, 

in acute catarrhal laryngitis, 
in pseudo-membranous croup, 
Calcarea carbonica, in chronic coryza, 
Camphor, in acute coryza, 
Carbo vegetabilis, in acute coryza, 
Chamomilla, in acute coryza, 

in spasm of the glottis, 
Chlorine, in spasm of the glottis, 
Coryza, acute, 

etiology of, 
nature of, 
symptomatology of, 
progress of, 
therapeutics of, 
general management of, 
aphorisms of, 
Coryza, chronic, 
varieties of, 
etiology of, 
symptomatology of, 
thermometry of, 
diagnosis of, 
prognosis of, 
general management of , 
therapeutics of, 
aphorisms of, 
Coryza, purulent, 
etiology of, 
symptomatology of, 
thermometry of, 
pathological anatomy of, 
prognosis of, 
general management of, 
therapeutics of, 
aphorisms of, 
Corallia rubra, in spasm of the glotti 
Croup, diphtheritic, 
history of, 
etiology of, 
symptomatology of, 
pathological anatomy of, 
prognosis of, 
tracheotomy in, 
general treatment of, 
therapeutics of, 
aphorisms of, 



36 
130 
232 
55 
30 
36 

33 
109 

99 
25 
26 
27 
27 
29 
29 
37 
38 
5i 
51 
5i 
52 
53 
53 
54 
54 
54 
63 
39 
4i 
42 

■44 
44 
46 
46 
47 
50 

108 

235 
236 
241 
244 
249 
266 
268 
274 

275 
286 



INDEX. 



305 



Croup, pseudo-membranous 

definition of, 

etiology of, 

symptomatology of, 

progress of, 

thermometry of, 

physical diagnosis of, 

essential nature of, 

pathological anatomy of 

diagnosis of, 

prognosis of, 

tracheotomy in, 

therapeutics of, 
. aphorisms of, 
Croup, scarlatinal, . 

definition of, 

etiology of, 

symptomatology of, 

pathological anatomy of 

diagnosis of, 

prognosis of, 

therapeutics of, 

aphorisms of, 
Croup, spasmodic, 

etiology of, 

physical diagnosis of, 

pathological anatomy of 

diagnosis of, 

prognosis of, 

therapeutics of, 

general treatment of, 

aphorisms of, 
Cyclamen, in acute coryza 

in chronic coryza, 
Cuprum metallicum, in spasm of the glottis 
Dulcamara, in acute coryza, 
Dunham, Dr. Carroll, on chlorine in s;asm of the glottis, 
Euphrasia, in acute coryza 
G-elsemium, in spasm of the glottis, 
Graphites, in chronic coryza, 

Hayward, on the local use of Aconite in acute coryza 
Hepar sulphuris, in acute coryza, 
in chronic coryza, 
in acute catarrhal laryngitis 
in spasmodic croup, 
in tracheitis. 



171 

173 
177 
190' 
199 
201 
202 
204 
206 
210 
214 
216 
218 

233 

288 

288 

289 

289 

290 

291 

292 

292 

293 

154 

157 

162 

162 

163 

163 

163 

168 

170 

36 

62 

106 

36 

100 

34 

95 

60 

37 

32 

62 

128 

166 

302 



306 



INDEX. 



Hering, Constantine, on the etiology of acute coryza, 
Hippocrates, on the general treatment of acute coryza 
Hydrastic canadensis, in chronic coryza, 
Hyosciamus, in acute catarrhal laryngitis, 
Ipecacuanha, in acute coryza, 

in spasm of the glottis, 
in acute catarrhal laryngitis, 
Ignatia, in spasm of the glottis. 
Iodine, in chronic coryza, 
in spasm of the glottis, 
in acute cedematous laryngitis, 
in pseudo-membranous croup, 
in diphtheritic croup, . 
Kali bichromicum, in chronic coryza, 

in pseudo-membranous croup 
in diphtheritic croup, 
Kali carbonicum, in chronic coryza, 
Kali hydrodicum, in chronic coryza, 
Lachesis, in chronic coryza, 

in spasm of the glottis, . 
in acute catarrhal laryngitis, 
in acute cedematous laryngitis, . 
in diphtheritic croup, 
Laryngitis, acute catarrhal, 
nature of, , 

etiology of, . - . 

symptomatology of, 
thermometry of, 
pathological anatomy of, 
aphorisms of, 
prognosis of, 
general treatment of, 
therapeutics of, 
aphorisms of, . 
Laryngitis, acute cedematous, 
nature of, 
varieties of, 
symptomatology of, 
progress of, 

pathological anatomy of, 
diagnosis of, 
prognosis of, 
therapeutics of, 
operative interference in, 
aphorisms of, . , 

Laurocerasus, in spasm of the glottis, 



38 
37 
62 

131 

36 

94 

131 

106 

62 

98 

148 

221 

278 

56 

227 

275 
60 
61 
60 
107 
130 
148 
284 
116 
117 
118 
118 
121 
122 
123 
124 
124 

125 
127 
132 
132 

133 
136 

137 
139 
140 
142 

143 
149 

152 
109 



INDEX. 



307 



Lobelia, in spasmodic croup, . ... 


168 


Lycopodium, in chronic coryza, . • . 


59 


Meigs, Dr. Chas. D., on the flannel cap in acute coryza, 


37 


Mercurius iodatus, in chronic coryza, 


62 


Mercurius solubulis, in acute coryza, 


3i 


in acute catarrhal laryngitis, 


130 


in tracheitis, 


301 


Moschus, in spasm of the glottis, 


88 


Nitric acid, in purulent coryza, 


48 


in chronic coryza, .... 


61 


Nux Vomica, in acute coryza, 


30 


in spasm of the glottis, 


108 


in acute catarrhal laryngitis, 


131 


Opium, in spasm of the glottis, 


108 


Phosphorus, in acute catarrhal laryngitis, 


130 


in spasmodic croup, 


167 


in pseudo-membranous croup, 


232 


Plumbum, in spasm of the glottis, 


107 


Pulsatilla, in acute coryza, . 


35 


in spasm of the glottis, 


108 


in acute catarrhal laryngitis, 


131 


Sanguinaria canadensis, in acute coryza, 


. . 36 


in spasm of the glottis, 


90 


in acute catarrhal laryngitis, 


127 


in acute cedematous laryngitis 


145 


in pseudo-membranous croup, 


228 


in diphtheritic croup, 


286 


in scarlatinal croup, 


292 


in tracheitis, . 


301 


Sambucus, in acute coryza, .... 


36 


in spasm of the glottis, 


87 


in acute catarrhal laryngitis, 


131 


Scald throat, 


138 


Sepia, in chronic coryza, .... 


58 


Silicia, in chronic coryza, .... 


55 


Spasm of the glottis, .... 


64 


nature of, ..... 


65 


etiology of, 


68 


symptomatology of, ... 


77 


mode of death in, ... . 


87 


therapeutics of, 


87 


general treatment of 


no 


chloroform in, . 


in 


tracheotomy in, .... 


in 


lancing of the gums in, 


112 


diet in, 


112 


aphorisms of, .... . 


114 



308 



INDEX 



Spongia, in spasm of the glottis, 

in acute catarrhal laryngitis, , 
in acute cedematous laryngitis, 
in spasmodic croup, 
in diphtheritic croup, 
in tracheitis, 
Stannum metallicum, in chronic coryza, 
Sulphur, in chronic coryza, 

in spasm of the glottis, 
in tracheitis, 
Tartar emetic, in acute catarrhal laryngitis, 
in pseudo-membranous croup, 
in diphtheritic croup, 
in tracheitis, 
Tracheitis, 

definition of, 
etiology of, 
symptomatology of, 
thermometry of, 
pathological anatomy of, 
diagnosis of, 
prognosis of, 
general treatment of, 
therapeutics of, 
aphorisms of, 
Veratrum album, in spasm of the glottis. 
Williams, Dr. C. J. B., on the thirst cure in acute coryza 
Zincum metallicum, in spasm of the glottis 



109 

128 
148 
165 
286 
301 
62 
54 
109 
302 
129 
231 
285 
301 
294 

295 
296 
296 
299 
299 
299 
300 
300 
301 
302 
109 

37 
108 



